Poland: ‘Abortion tourism’ reflects restrictive law

Leading Polish activists held a civil hearing at the Polish parliament on 26 August on the rising number of Polish women who are travelling abroad to obtain access to abortion. 

Doctors from Germany, Austria, the Netherlands, and Britain who regularly treat Polish women also attended the meeting, Ms Magazine reports.

A doctor’s written notice authorising an abortion procedure is required to obtain an abortion in Poland, where strict abortion laws only allow abortion in cases of a threat to a woman’s life or health, severe and permanent handicaps of the fetus, and rape or incest. The Catholic Church was influential in a 1993 compromise that led to Poland’s current abortion laws.

Poland, a country of 38 million where the Catholic Church retains considerable clout, has one of the most restrictive abortion laws in the 27-nation European Union.

Official statistics show only several hundred abortions are performed every year, but pro-choice campaigners say underground abortions are very common, Reuters reports.

‘We estimate… that on average 150,000 abortions are performed per year,’ Wanda Nowicka, head of the Polish Federation for Women and Family Planning, told the meeting. ‘Of this number, some 10-15 percent of abortions are performed abroad and this number is definitely growing.’

The doctors said women sought abortions abroad because they were illegal at home and often performed in poor conditions, and they fear social ostracism. An illegal abortion in Poland costs 2,000-4,000 zlotys ($640-$1,270), compared to 400-600 euros ($510-$760) in Germany, 280 euros in the Netherlands and 450-2,000 pounds ($700-$3,120) in Britain, they said.

The website of the Polish Federation for Women and Family Planning notes that most women go to Poland’s East and South neighbouring countries, for example Lvov (Ukraine), Druskienniki (Lithuania), Kaliningrad (Russia), Minsk (Bielorus), the Czech Republic and Slovakia. Fewer women can afford to seek abortion in Western countries, but those that do most frequently go to Holland, Germany, Belgium and Austria.

The British media has previously reported ‘abortion tourism’ from Poland in scandalised terms, claiming that women are frequently travelling to the UK to get abortions free on the National Health Service.

Ann Furedi, chief executive of BPAS, said:

‘In 2009 just 20 Polish women were included in the official statistics for the number of women from overseas who had abortions in Britain. However, this does not include the many Polish women who are able to claim free NHS care because they are registered to work or studying, are resident in Britain. Arrangements now exist for reciprocal health care between European countries.

‘Privately paid for abortions in Britain are relatively expensive; but Polish women are smart and who can blame them if they travel to get the care they need. No one knows exactly how many Polish women have abortions in Britain - it may be thousands. At BPAS we treat, without prejudice, anyone who wants our care and is lawfully able to receive it.’

Poland lost a case in the European Court of Human Rights in 2007 to Alicja Tysiac, who nearly went blind after giving birth to a third child following failed attempts to find a doctor who would perform a legal abortion for her.

More Polish women seen seeking abortions abroad. Reuters, 26 August 2010

Polish Parliament Hearing Held Regarding Women Traveling for Abortions. Ms magazine, 27 August 2010

Poland: ‘Abortion tourism’ ad causes reaction in UK. Abortion Review, 17 March 2010

UK: Health Protection Agency warns of rise in sexually transmitted infections

There were almost half a million new cases of STIs in the UK last year, figures show.

Experts at the Health Protection Agency (HPA) say young people are most affected, BBC News Online reports. And one in 10 of 15-24 year olds with an STI become infected again within a year.

Health ministers said they would look at what more could be done to increase young people’s awareness of risks.

The 482,696 new cases represent a 3% rise from the 2008 figures, continuing a ‘steady upward trend’ that the HPA said had been seen over the past decade.

Urban and deprived areas have the highest rates of STIs. Hotspots include Hackney and Lambeth in London, as well as Nottingham, Manchester and Blackpool.

The rise is in part due to more testing, and the use of tests which are more sensitive at picking up signs of an infection - but experts believe unsafe sexual behaviour is also part of the story, BBC News Online reports.

Dr Gwenda Hughes, an STI expert at the HPA, said:

‘These figures highlight the vulnerability of young women. Many studies have shown that young adults are more likely to have unsafe sex. Often they lack the skills and confidence to negotiate safer sex. Re-infection is also a worrying issue. Teenagers are repeatedly putting their own and others’ long-term health at risk.’

There were 217,570 diagnoses of chlamydia in 2009 - a 7% increase on the previous year. Cases of genital herpes went up by 5% to 30,126.

And diagnoses of gonorrhoea have gone up by 6% from 16,451 cases in 2008 to 17,385 last year.

The HPA says the bacteria which cause gonorrhoea are becoming more resistant to the most commonly used antibiotics.

Professor Cathy Ison, from the agency’s Centre for Infections, said:

‘We could see gonorrhoea becoming a very difficult infection to treat within the next five years. The infecting bacteria are very versatile. We’re trying to encourage companies to develop effective new antibiotics.’

Sexual health charities described the figures as ‘alarming’ and joined the HPA in urging people to use condoms, and to have a health check if they have had unsafe sex.

Health Minister Paul Burstow said:

‘Left untreated, STIs can lead to infertility. We’re going to look at what more can be done to increase young people’s awareness of risks, to prevent infection and to access screening and treatment.’

Sexually transmitted infections near 0.5m a year in UK. BBC News Online, 25 August 2010

Sexually transmitted infections reach almost half a million: Young women most at risk. Health Protection Agency, 25 August 2010

Wales: Teenage conception figures released

More than half of teenage conceptions in Wales end in abortion, the Western Mail reports.

Just under 60% of girls under 16 who find themselves pregnant now opt to have a termination, with 48% of under-18s choosing the procedure. This is an increase from five years ago, when the abortion rate was around 50% for under-16s and 40% for under-18s.

Overall, the number of teenage conceptions in Wales has fallen, with the figures for the first half of 2009, the most recent available, 8.65% lower than the year before.

An Assembly Government spokeswoman said:

‘We are continuing to work towards decreasing rates of conception for women under 18 in Wales as many of these pregnancies are unplanned. An abortion is an extremely difficult decision for women, whatever their age. It is the role of the Assembly Government and the NHS in Wales to ensure appropriate access to help, information and support to women considering this option and safe care and treatment if required.’

The Assembly Government is soon to publish its Sexual Health and Wellbeing Action Plan for Wales 2010-2015, which will set out how it intends to improve sexual health in Wales, the Western Mail reports.

A key component of the document is the need for an integrated response to tackle teenage pregnancies that will focus on those most vulnerable and address the wider issues such as the reduction of child poverty, raising the standard of education and the provision of good quality youth services. This will follow work under way in schools and be supported by school nurses in secondary schools.

A spokeswoman for abortion advice charity BPAS said teenagers were now more likely to be aware of how to access abortions than in the past, with most now carried out on the NHS.

Teenagers and those in their twenties are far more likely to choose to have abortions than older women – 11.4% of pregnancies among 30 to 34-year-olds end in abortion. Overall, 20.5% of pregnancies in Wales end in a termination.

The rate of teenage conceptions varies between local authority areas, with some seeing large increases while others see continued falls.

In Rhondda Cynon Taf the number of teenage pregnancies has dropped by a third year on year to the lowest in 12 years. But the Vale of Glamorgan saw a year-on-year increase of 61.9% to its highest numbers since June 2002.

Most teen pregnancies end with abortions. By Claire Miller, Western Mail, 25 August 2010

USA: Internet searches and abortion availability

A study by two Children’s Hospital doctors has found that searches on ‘abortion’ rise in areas with more conservative abortion policies or where the procedure is less available.

Dr. Ben Reis and Dr. John Brownstein of Children’s Hospital Boston Infomatics Program reviewed the abortion rates and policies in 50 states and 37 countries and compared the information against the number of Internet searches for the word ‘abortion’.

They found more searches in states and countries with more restrictive policies or less access to abortion and lower abortion rates.

‘In places where abortion access is readily available, people can go to their mainstream health care providers,’ Reis suggested. In areas with more abortion searches, he said, ‘people may be going on the Internet to find alternate routes.’

He said the pattern was found in every state and country studied, the Boston Herald reports.

‘We were actually very surprised. There is a very consistant, strong relationship,’ Reis said.

The study was published in the medical journal BMC Public Health.

‘Abortion’ Googled more in conservative areas. Boston Herald, 25 August 2010

Measuring the impact of health policies using Internet search patterns: the case of abortion. Ben Y Reis and John S Brownstein. BMC Public Health 2010, 10:514doi:10.1186/1471-2458-10-514

UK: Fertility regulator considers donor payments

The Human Fertilisation and Embryology Authority is considering increasing compensation for egg and sperm donors.

Women who donate eggs are currently paid £250, but this could rise considerably under moves to address egg and sperm shortages at IVF clinics, BBC News Online reports.

Many fertility clinics have long waiting lists, driving some childless couples abroad.

A spokesperson for the Human Fertilisation and Embryology Authority (HFEA) told the BBC: ‘We will be looking at a number of issues related to donation policies, one of which will be compensation given to donors. We haven’t decided on a figure.’

The HFEA is holding a three-month public consultation into its donation policies, starting in January 2011. No decision will be made until the end of the consultation.

It follows concern over the number of Britons travelling to countries such as Spain to receive IVF because of shortages of donated eggs and sperm in the UK.

In the UK, egg and sperm donors cannot be paid but can claim ‘reasonable expenses’ for travel and loss of earnings. This is limited to a maximum of £250 per cycle of egg donation or course of sperm donation. Some fertility experts say this is too low to attract donors, and they should be paid more for their time and efforts.

Susan Seenan of the support group Infertility Network UK said it was right to look at all the policies surrounding egg and sperm donation.

She said: ‘We know that many patients are travelling abroad for treatment, often because of the severe lack of sperm and egg donors in the UK. Although many patients do receive a high standard care abroad, this is not ideal and the rules and regulations in other countries can be totally different from that in the UK.’

Seenan said patients deserved access to safe, regulated treatment in their own country, and there was a need to find some way of increasing the number of both sperm and egg donors in the UK.

At a debate organised by Progress Educational Trust and the Royal Society of Medicine in 2009, experts suggested that one of the key reasons for the shortage of donor gametes in the UK was the removal of donor anonymity in 2005. 

Egg donor expenses ‘under review’. BBC News Online, 23 August 2010

Banking Crisis: What should be done about the sperm donor shortage? Abortion Review, 1 July 2009

AR update, 21 August 2010

Judge condemns forced contraception plan; GPs to gain commissioning powers; next-generation emergency contraceptive pill gains approval from the Food and Drug Administration, and more ...

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A quarterly news digest is provided in the print edition of Abortion Review. You can download the print edition for free here.

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- 1. UK: JUDGE CONDEMNS FORCED CONTRACEPTION PLAN

A council’s plan to force contraception upon a woman with a low IQ was ‘essentially a horrendous prospect’ that has ‘shades of social engineering’, a judge has said.

Mr Justice Bodey said he could not see how it could be acceptable for the court to impose contraception ‘by way of physical coercion’. He said the local authority’s plan, to stop the 29-year-old woman having more children, ‘would raise profound questions about State intervention in private and family life’.

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- 2. MOTHERHOOD, ABORTION AND PARENTING CULTURE

At a recent conference, supported by BPAS, academics from the UK and USA discussed new challenges to women’s autonomy:

-- Abortion and reproductive decision-making in a culture of ‘intensive parenting’;
-- Assisted conception and the limits of choice;
-- The pregnant woman’s autonomy in an era of increasing lifestyle surveillance and sensitivity to fetal harm;
-- Changing ideas about motherhood and fatherhood.

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- 3. UK: GPs TO GAIN COMMISSIONING POWERS

GP practices are set to be handed responsibility for most health services under ministerial plans for a radical shake-up of the National Health Service in England.

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- 4. USA: ‘ELLA’ EMERGENCY CONTRACEPTIVE PILL WINS FDA APPROVAL

A next-generation emergency contraceptive pill that can prevent unwanted pregnancy up to five days after unprotected sex has gained final approval from the Food and Drug Administration.

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- 5. UK: MAJOR PHARMACY PLANS TO SELL EMERGENCY CONTRACEPTION ONLINE

Boots has launched a website enabling customers to purchase certain treatments online without the need of a prescription.

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- 6. USA: IMMEDIATE POSTABORTAL INSERTION OF INTRAUTERINE DEVICES

In this study, from the Cochrane Database of Systematic Reviews, the authors concluded that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher than after interval insertions. However, IUD use is higher at six months with immediate than with interval insertion.

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- 7. UK: GOVERNMENT CONSULTATION ON FAMILY PLANNING IN THE DEVELOPING WORLD

The UK Government is to ‘put family planning at the heart of its approach to women’s health in the developing world’ in an attempt to reduce the persistently high number of women who die in pregnancy and childbirth, the Secretary of State for International Development has announced.

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- 8. ‘CHOOSING TOMORROW’S CHILDREN’

John Gillott reviews Stephen Wilkinson’s new book on the ethics of selective reproduction. 

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- 9. ‘ALWAYS GLAD TO RECEIVE IT’: RESULTS OF THE ABORTION REVIEW READERS’ SURVEY

Many thanks to those of you who took part in our 2010 survey. We received dozens of responses from readers around the world.

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ABORTION REVIEW UPDATES

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For news updates from the UK, see here.

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For news updates from around the world, see here.

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For updates from the medical press, see here.

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UK: Judge condemns forced contraception plan

A council’s plan to force contraception upon a woman with a low IQ was ‘essentially a horrendous prospect’ that has ‘shades of social engineering’, a judge has said.

Mr Justice Bodey said he could not see how it could be acceptable for the court to impose contraception ‘by way of physical coercion’, the Press Association reports.

He said the local authority’s plan, to stop the 29-year-old woman having more children, ‘would raise profound questions about State intervention in private and family life’.

The judge’s decision was published by the Court of Protection, which has jurisdiction over the property, financial affairs and personal welfare of people who lack the mental capacity to make decisions for themselves, last month.

The council, which also cannot be named, originally wanted to force contraception on a married woman who has an IQ of 53. Fears that she would not be able to look after her children have already led to social services putting the two children she already has up for adoption, the court heard.

But her husband, a man with an IQ of 65, was accused of using ‘violent and bullying behaviour’ to stop her taking contraception because he wanted a baby, so the council began court proceedings to ‘protect her interests’.

Mrs A’s social worker said the pair would not co-operate with anything involving coercion and admitted ‘there would need to be police involvement’ for her to be ‘physically removed from the family home and taken to have contraception under restraint and anaesthesia’.

The judge said:

‘It is obvious, on the facts of this case, that any step towards long-term court-imposed contraception by way of physical coercion, with its affinity to enforced sterilisation and shades of social engineering, would raise profound questions about State intervention in private and family life. Whilst the issue of the use of force has not been argued out at this hearing I cannot, on these facts, presently see how it could be acceptable.’

Forced contraception plan condemned. PA, 20 August 2010

Mother speaks out against council over forced contraception bid on daughter. Daily Telegraph, 20 August 2010

Mental disability, state power and the capacity to decide, by Wayne Martin. Guardian, 20 August 2010

UK: Study leads to claims about alcohol and abortion

An article in the Daily Mail claims that ‘the devastating effects of excess alcohol on young women have been spelled out by a major study’, finding that ‘binge drinking “ladettes” are 40 per cent likelier to have an abortion’.

Researchers from University College London examined the alcohol consumption and sexual activity of almost 25,000 individuals aged 16 to 44 over a ten-year period. They found that women who drank in excess – more than 14 units a week – were 1.8 times more likely to have taken emergency contraception such as the morning after pill at least once over the last year, the Mail reports. They were also 1.4 times likelier to have had at least one abortion in the last 18 months.

In fact the study, published in the Journal of Public Health, found no association between heavy drinking and using emergency contraception or accessing abortion. In their paper, the authors write:

‘The drinking behaviours we measured increased between 1990/91 and 2000/01 in the British population, with the proportion of heavy drinkers tripling over this time. Both surveys observed greater numbers of partners and some sexual risk behaviours among those drinking in excess of the recommended limits.

‘As the magnitude of these relationships has remained the constant, this suggests that the interrelated public health issues of sexual risk-taking and heavy drinking increased in scale during the 1990s. For example, we found that those who usually drank in excess of recommended limits at the time of the interview were more likely to report unprotected sex with multiple partners and poor contraceptive choices.

‘Female heavy drinkers were more likely to report using emergency contraception in the year prior to interview, although not after adjusting for partner numbers and sociodemographics, and no association was observed with reporting an abortion in the previous 5 years. However, non-use of reliable contraception at first intercourse was reported more often by respondents who gave being drunk as their main reason for sex.’

Ann Furedi, chief executive of BPAS, said:

‘Women can have unintended pregnancies for a number of reasons, which is why it is important that emergency contraception and abortion are available to those who need it. If women are less likely to use contraception when they are drunk, surely it is good news that they are able to access the morning after pill when they sober up?’

Legacy of the ladette: Now alarming rise in teenage promiscuity and abortions is linked to women’s binge drinking, by Sophie Borland. Daily Mail, 21 August 2010

Alcohol misuse, sexual risk behaviour and adverse sexual health outcomes: evidence from Britain’s national probability sexual behaviour surveys. Aicken CR, Nardone A, Mercer CH. Journal of Public Health (Oxf). 2010 Aug 12.

USA: Anti-abortion campaigners turn on student insurance

A battle has broken out over abortion coverage in student insurance plans at the University of North Carolina. 

Robin Marty, writing on RH Reality Check, gives a round-up of the row:

‘At the center of the battle was the school’s mandate that all students must be covered by some form of medical insurance - a rule that occurs at most public and private universities.  Should the student not have insurance, either their own personal policy of coverage via their parents’ policies, they would be required to purchase insurance through the school at a cost of about $350 or $375 per semester, or $700 to $750 a year.

‘Most people would be excited to have such affordable insurance with the skyrocketing costs of healthcare.  Students, especially, rely on preventive healthcare to keep serious illness at bay, when complications could not only cost them lost time in the classroom but also lost money on tuition.

‘But the anti-choice students on campus discovered that among the many benefits being provided in their affordable plans was one they simply could not accept - coverage for elective abortions...’

Read the full article here:

Student Insurance and Abortion: A Battle at University of North Carolina, by Robin Marty. RH Reality Check, 18 August 2010

USA: ‘Ella’ emergency contraceptive pill wins FDA approval

A next-generation emergency contraceptive pill that can prevent unwanted pregnancy up to five days after unprotected sex has gained final approval from the Food and Drug Administration, the Money Times reports.

Developed in government laboratories, Ella will be dispensed as a single dose. Women will need a prescription but could keep a supply at home. The pill prevents pregnancy from occurring when taken within 120 hours (5 days) of unprotected intercourse or contraceptive failure.

Watson Pharmaceuticals, Inc., of Morristown, N.J., will begin preparations to commercialise the novel type of emergency contraception pill from French pharmaceutical company HRA Pharma of Paris in the fourth quarter this year, under an exclusive distribution agreement, according to US tabloid reports.

Developed in government laboratories, Ella will be dispensed as a single dose and women will need a prescription but could keep a supply at home. The pill prevents pregnancy from occurring when taken within 120 hours (5 days) of unprotected intercourse or contraceptive failure.

Approved last year in Europe, Ella is now available in at least 22 countries under the brand name ellaOne. Formulated as a 30-mg tablet, the pill is a progesterone agonist/antagonist that inhibits or delays ovulation.

In June 2010, Ella was unanimously endorsed by the Reproductive Health Drugs Advisory Committee of the FDA, agreeing that the drug was safe and found no evidence it was capable of terminating an existing pregnancy. Ella was proved effective and safe in two phase 3 clinical trials.

On 13 August, the FDA granted approval for the marketing of the pill in the United States, where it will compete with Teva Pharmaceutical Industries Ltd.’s Plan B, the morning-after pill now available over the counter to women 17 and older. The Plan B pill is only effective in the first 72 hours, while Ella can be taken within 120 hours, or five days, of unprotected intercourse or failure of some other contraceptive method.

The FDA said that women who are pregnant, or suspect that they are pregnant, and those who are breastfeeding should not use this product.

‘As a pioneer and a leader in the field of emergency contraception, HRA Pharma is committed to providing women and their health care providers highly effective contraceptive options,’ said Erin Gainer, CEO of HRA Pharma. ‘Ella, an effective and well-tolerated new generation emergency contraceptive, fulfills a significant and previously unmet need in this field by reducing pregnancy risk up to five days after intercourse.’

5-day-after Ella contraceptive pill wins FDA approval. The Money Times, 14 August 2010

Also read:

Is Ella Birth Control or Abortion? By Sarah Elizabeth Richards. Slate, 17 August 2010

Ulipristal acetate versus levonorgestrel for emergency contraception. Abortion Review, 29 January 2010

UK: Major pharmacy plans to sell emergency contraception online

Boots has launched a website enabling customers to purchase certain treatments online without the need of a prescription, the Daily Mail reports. 

The chemist says it hopes to expand the service to include most other drugs available in-store - including the emergency contraceptive pill.

Normally, users must see their GP or pharmacist for a consultation before they are given the treatment. Usually sold under the name Levonelle, the emergency contraceptive pill can be bought from pharmacies for £25. But if it is made available over the internet, they will need only to fill in an online form and make a payment for the contraceptive to be delivered by post the next day, the Daily Mail reports.

The emergency contraceptive pill is already available online from some sources including Lloyds Pharmacy. The BPAS service bpasbypost offers a range of online doctor services including prescriptions for the pill, prescriptions for the emergency contraceptive pill, testing for STIs, treatment for STIs, free online assessments into the likely cause of male impotence, and impotence treatment by post. bpasbypost is run by the online medical service DrThom, which is regulated and registered with the Healthcare Commission to manage patients online.

The Boots Prescriptions Direct website enables customers to buy certain treatments such as anti-malarials, hair loss treatments and drugs to help quit smoking without the need of a prescription, the Daily Mail reports.

The chemist’s professional standards director, Paul Bennett, said: ‘We’re expecting this service will be expanded to include emergency hormonal contraceptives - the morning after pill. The opportunity to expand certainly exists. It is a very exciting development.’

Peter Saunders, chief executive of the Christian Medical Fellowship, said:

‘The danger is that the morning after pill would be easily available to young girls without them seeing a doctor. This would encourage them to think of it as a safety mechanism and this may well promote greater promiscuity. There is also still the risk of pregnancy - as it isn’t always effective. And there is the concern that young girls entering a sexual relationship too early will suffer emotionally when it breaks down. It’s putting company profits before women’s health.’

Boots sells the morning after pill on the internet: Outcry at plan that could let under-16s ‘stock up’ without seeing a GP. Daily Mail, 13 August 2010

USA: Poll finds that young Hispanics are less likely to be Catholic

An Associated Press-Univision poll of 1,500 Latino adults also found significant divisions on social issues such as same-sex unions and abortion, along lines of age, language and whether one is Catholic or Protestant.

Overall, 62 percent of Hispanics identify as Catholic, but that includes only 55 percent of young adults 18 to 29, compared with 80 percent of elders 65 and over, the Associated Press reports.

Catholicism is the primary religion in the ancestral countries of US Latinos. But this poll found, today in the USA, that religious sentiment seems to be keener among Latino Protestants than their Catholic counterparts. Protestants are twice as likely to attend weekly services, and they tend to be more conservative than Catholics on matters of religious doctrine and social morality.

Seventy percent of Hispanic Protestants said the Bible is the actual word of God, to be taken literally, compared with 46 percent of Hispanic Catholics. Just 26 percent of Protestants said abortion should be mostly legal, compared with 41 percent of Catholics. And 59 percent of Protestants said same-sex couples should not be allowed to marry, compared with 29 percent of Catholics.

The poll found a large generation gap on same-sex marriage, with 46 percent of Hispanics ages 18 to 29 saying same-sex couples should be allowed to marry, compared with less than one-third of those in older age groups. Same-sex marriage seems to be gaining acceptance in Latin America, AP reports. Last month, Argentina became the first South American nation to allow it. Gay marriage is also legal in Mexico City, while same-sex civil unions granting are allowed in Uruguay and in some states in Mexico and Brazil.

On another divisive issue, the poll found markedly less support for legal abortion among Latinos than among Americans overall. Thirty-nine percent of Hispanics said abortion should be mostly legal, compared with 51 percent of the general population in a 2009 AP-GfK poll. But there are big disagreements among Latinos. Forty-nine percent of those who speak mainly English said abortion should be legal in most cases, about the same as the proportion of the general US population holding a similar view. Hispanics who mainly speak Spanish were far more conservative, with only 31 percent saying abortion should be mostly legal.

Poll: Young Hispanics less likely to be Catholic. Associated Press, 11 August 2010

Ireland: Economic crisis and the abortion debate

An article published by Reuters suggests that the economic recession is encourging more women to seek abortions.

Terminating a pregnancy has long been a fraught issue in Ireland, where one of the strictest abortion laws in Europe allows it only when the mother’s life is in danger, reports Reuters.

Women who have an abortion still face a maximum sentence of life imprisonment, driving thousands abroad each year, mainly to Britain. Even that is a little more liberal than before a 1992 referendum, which gave women the freedom to receive abortion information and travel abroad to terminate pregnancies.

Today, following the former ‘Celtic Tiger’s’ slide from boom to bust, Reuters suggests that the economic recession is encourging more women to seek abortions, although the article notes that statistical evidence is hard to find.

Last year, 15 percent of the 1,300 women who visited the Dublin Well Women Center cited financial problems as the main reason for seeking information on terminating a pregnancy.

‘Financial pressure might have always affected a women’s decision around whether she continued with her pregnancy but in the last year there was some sort of shift in the priorities,’ Alison Begas, chief executive of the center, said. ‘She would say she had lost her job, or her salary had been cut or even those for whom the guy has lost his job.’

Ireland crawled out of the longest recession of any euro zone country in the first quarter of this year, but sustained economic recovery is some way off, Reuters reports.

Ann Rossiter, a London-based Irish author who for years helped Irish women seek terminations in Britain, has warned that the credit crunch could bring a return to illegal abortions.

Abortions in UK clinics start from 350 pounds ($551). There are also travel costs. ‘I see no reason why we wouldn’t have a return to the backstreet or self-induced abortions,’ she said.

Between 1980 and end-2009, at least 142,060 women travelled for abortion services in England and Wales, according to the Irish Family Planning Association (IFPA).

Last year, 4,422 women providing Irish addresses had terminations in England and Wales, British figures show, down 178 on 2008. Numbers have fallen since 2001.

But IFPA says the figures are an underestimate as not everyone wants to provide their address for confidentiality reasons, and women also travel to the Netherlands.

Women in Catholic Poland also face strict laws. Official statistics show several hundred abortions performed annually but pro-choice campaigners estimate hundreds of thousands are performed underground or abroad, sometimes in poor conditions, Reuters reports. Traditionally Catholic Spain has changed its law making it easier for women to have a termination but some conservative-led regions have refused to allow their hospitals to perform them.

In decades of debate in Ireland both pro-choice and pro-life campaigners have had their victories.

A March YouGov poll for British sexual health consultants Marie Stopes showed 78 percent of those questioned supported abortion if the pregnancy endangers a woman’s health or is the result of sexual abuse, rape or incest. A month later, a poll for the Pro-Life Campaign showed support for a continued ban, with 70 percent in favor of constitutional protection for the unborn child.

Ireland is defending its abortion law at the European Court of Human Rights, countering a legal challenge by three women who said it endangered their health and violated their rights. The two Irishwomen and a Lithuanian living in Ireland went to Britain for abortions.

‘I think it could be the case that gets the political system really focused on trying to resolve the issue,’ said Niall Behan, chief executive of IFPA, which supports the women.

While the court is unlikely to rule on the substance of Ireland’s abortion law, it could say it is deficient in respecting the right to private life of those concerned, said Adam McAuley, a law lecturer at Dublin City University. But he sees no immediate change. ‘The state will probably dilly-dally, I can’t see it being quick,’ he said. ‘The reality is (politicians) can just see votes being lost on this rather than being gained.’

Economic crisis rekindles Irish debate on abortion. Reuters, 11 August 2010

Russia: Dairy boss threatens to sack women who have abortions

The head of a Russian dairy company has said the company would dismss Russian Orthodox Christian employees who have abortions or refuse a religious marriage.

Vassili Boiko-Veliki, president of Russkoe Moloko, said those women who had had abortions, or chose to have one in the future, would face dismissal, BBC News Online reports.

‘Abortion is the murder of someone,’ he told the radio station, Ekho Moskvy. ‘We do not want to work with murderers’.

Mr Boiko-Veliki was also quoted as saying that newly-hired employees who had been married in civil ceremonies would be given three months to have a religious wedding.

Even employees from other religions would be obliged to receive instruction about Russian Orthodox culture, he said.

According to Ekho Moskvy, Mr Boiko-Veliki has said that the record heatwave that hit Russia in recent weeks was divine retribution for sins committed in the past.

Critics said the rules violated labour laws and the constitution.

Russian dairy to sack women who have abortions. BBC News Online, 12 August 2010

Argentina: Human Rights Watch criticises abortion provision

A report by the New York-based organisation claims that 40 percent of Argentine pregnancies end in abortion, most of which are carried out clandestinely and are the leading cause of maternal mortality.

Argentina’s rate of abortion, which is outlawed in most circumstances, is twice the regional average due to a reproductive health-care system that is ‘negligent’ and ‘abusive’, Human Rights Watch claimed on 10 August.

Abortion is only legal in specific circumstances in Argentina, for example if the pregnancy is the result of a rape or poses a mental or physical risk. Yet very few such abortions are actually carried out, either because doctors refuse to provide them or because the women are forced to go to court to make their case, the report found.

Abortion is an almost taboo issue in Argentina, a predominantly Roman Catholic country that was one of the last Latin American nations to abandon population growth as a policy, Reuters reports.

‘What you have in Argentina is a much longer history of the government ignoring the problem of abortion than in the rest of the region,’ said Marianne Mollmann, author of the Human Rights Watch report Illusions of Care: Lack of Accountability for Reproductive Rights in Argentina. ‘There has generally been progress in the rest of the region ... but nothing has changed here in the past five years.’

The report found women had trouble buying contraception, were treated with general suspicion by doctors and subjected to illegal demands for their spouse’s permission during medical care.

Argentine President Cristina Fernandez has made human rights issues a cornerstone of her presidency and last month Argentina legalised gay marriage, making it the first country in Latin America to do so, Reuters reports. But Human Rights Watch said women’s ability to exercise their reproductive rights has not improved during Fernandez’s term, which began in 2007. The report’s authors noted that former Health Minister Graciela Ocana declared publicly that abortion was a matter of criminal law and not under her purview. Fernandez has said she is against legalising abortion.

‘The Argentine government’s actions are erratic or absent. The situation could get worse if this problem is not more vigorously tackled,’ said Jose Miguel Vivanco, director of Human Rights Watch’s Americas Division.

Argentina system said to lead to high abortion rate. Reuters, 10 August 2010

Illusions of Care: Lack of Accountability for Reproductive Rights in Argentina. Human Rights Watch, 10 August 2010

‘Choosing Tomorrow’s Children’

John Gillott reviews Stephen Wilkinson’s new book on the ethics of selective reproduction. 

Many of the issues discussed in this book have been debated in the literature and a number of academic and semi-popular book-length treatments of the issues exist, such as the excellent From Chance to Choice and Choosing Children by Allen Buchanan et al and Jonathan Glover respectively. Wilkinson’s USP is his focus on selection, and in particular his critical engagement with arguments against free parental choice in this area. Throughout he combines an informative and insightful analysis of concrete cases, including: sex selection for non-medical reasons; saviour siblings; and the deliberate selection of disability, with a discussion of more speculative future possibilities.

Reflecting his professional expertise the analysis is largely philosophical. An important distinction is choices between different possible future children and decisions about how many children to have (if any). This distinction - between same and different number choices - sheds an interesting light on some familiar issues. For example, contrary to a popular argument, he finds it less problematic if a saviour sibling is the product of a different number choice than if she is the product of a same number choice, thus eschewing the popular defence ‘but we wanted another child anyway’. His own primary interest is in the former, same number choices, for these are, he argues, the kinds of choices and decisions that are commonly made. Wilkinson is very much in favour of parental choice. He does however argue that some choices are morally problematic.

There is much in this book with which I agree. I particularly liked his discussions of the ‘expressivist’ arguments against selection and the social model of disability. His critique of the HFEA’s arguments against allowing the selection of a ‘saviour’ for a parent and against social sex selection in the UK because it would send the wrong signal to the rest of the world are nicely done.

There are though some areas where the focus on selection as a defining issue seems a little misplaced. The discussion of the deliberate selection of an embryo with a genetic impairment is one example. For Wilkinson, individual child welfare arguments allow the selection of an embryo with an impairment over a healthy one (a same number choice). This is because the child once she exists could not have existed otherwise and, presuming her to have a life worth living, she can only welcome the parents’ choice. He contrasts this situation sharply with a hypothetical one in which a healthy embryo is genetically manipulated to give it an impairment. In this case, he argues, the future child could complain that she had been adversely affected by the parents’ actions (or the embryologists, under parental instruction).

But is the distinction really so clear? Suppose a parent wanted a deaf child, and was discussing the issue with her embryologist after test results on embryos that were ready to be implanted had shown one had an impairment that would cause the future child to be deaf. What if the prospective parent were to say, ‘rather than throwing the rest away could you deafen one and implant it as well, to give me a greater chance of a child?’ If a child were to be born from the deafened embryo, the parent could say to that child, just as she could to the child with the congenital deafness, that it was a choice between being born deaf, or not being born at all, because there was no way she wanted a healthy child and it was her clear choice to have the healthy embryos destroyed. While there are no doubt distinctions to be drawn, the distinctions, I would suggest, give too much weight, inadvertently perhaps, to essentialist and teleological arguments, and too little weight to the issue of parental motivation.

A second example is his treatment of two topics, eugenics and enhancement, focusing on the selection of traits. In the case of eugenics this is too narrowly logical. Eugenics of old was more about the moral character of people, and the fear that the national ‘stock’ was degenerating because the ‘wrong’ kind of classes or races of people were having more children than the ‘right’ groups. Trying to untangle this through a philosophical study of different kinds of trait selection, in particular using the idea that negative selection against one trait is necessarily positive selection for another, is to use the wrong tools in my view.

Wilkinson then connects the discussion of positive and negative trait selection with the debate about enhancement. For different reasons this also seems strained to me. In his view selection can be a defining aspect of enhancement, or can create an enhancement. To give a concrete example, according to both of the definitions of enhancement he discusses, selection in favour of extremely high intelligence (a futuristic scenario) is classed as enhancement. What would be happening in that situation is what might occur through sexual intercourse without selection - the birth of an individual at the extreme end of the existing naturally-given spectrum, with a genome produced through the fusion of sperm and egg, unmodified by human manipulation. Is the selection of what can occur by chance enhancement? He acknowledge that some writers view enhancement as meaning modification rather than selection, but unfortunately he doesn’t discuss their arguments or his reasons for not using their definition.

Deliberate choice of disability, eugenics and enhancement are points for ongoing debate of course. Overall the book is quite evidently based on a deep understanding of the issues. If there is an overall problem with it, and this is sometimes a strength rather than a problem, it is that there are many issues that could have been dealt with in more depth, that Wilkinson is forced to touch on but then plead lack of space to develop. But such deficiencies, if they are such, leave the reader with plenty to chew on and discuss.

Choosing Tomorrow’s Children: The Ethics of Selective Reproduction, by Stephen Wilkinson. OUP 2010. 256pp hbk.

John Gillott is Innogen Postgraduate Student at the Open University. This review first appeared on the Pro-Choice Forum website.

Choosing Tomorrow’s Children is also reviewed by Iain Brassington in BioNews (561).

UK: Advertising watchdog rejects abortion ad complaints

Complaints about the first UK television advertisement by an abortion advisory organisation have been rejected by the Advertising Standards Authority.

The 1,054 complaints from the public, GPs, counsellors and MPs objected to Marie Stopes’s ‘Are you late?’ advert. Critics said the campaign in May and June for advice on unplanned pregnancy was misleading, offensive and harmful. The ad, which ran on Channel 4, drew the seventh highest number of complaints to the Advertising Standards Authority (ASA) of all time, BBC News Online reports.

But the Advertising Standards Authority said it did not mention or advocate abortion.

Viewers complained that it promoted abortion, offended their religious beliefs, did not take into account the views of fathers, was sexist for implying that pregnancy was solely a woman’s responsibility. Some were worried that it would actively encourage viewers to have an abortion. Others said the advert turned abortion into a consumer service.

Another concern hinged on whether the ad misled viewers by not referring to the physical and mental health risks of abortion and failed to mention that pregnant women who wanted advice could contact their GPs or seek the advice of family members.

Marie Stopes International defended its campaign, saying it did not mention abortion and did not promote the procedure, but aimed to draw attention to its advice line for any women concerned about a missed period or unplanned pregnancy. It said by showing a range of women in different circumstances, the ad was intended to ‘dispel the often-repeated myth that unplanned pregnancy was experienced mainly by young, feckless, single women’.

Rejecting the complaints, the ASA said the issue of abortion was controversial and distasteful to some, and acknowledged that many complainants interpreted that ad as a promotion of the procedure. But is said the commercial was for an advice service for women dealing with an unplanned pregnancy and did not focus on any one service or mention abortion.

The ASA said:

‘We understood that post-conception decisions could be very difficult, but considered the ad dealt with the issue of possible pregnancy in an understated way and was not sensationalist. The women featured in the ad looked deep in thought, and we did not therefore consider that the ad trivialised the dilemma of an unplanned pregnancy. Whilst the ad featured three women, we did not consider that it suggested that only the woman would be affected, or that she should take any decisions alone.’

The watchdog said it did not consider that the ad focused on or advocated any particular choice or course of action over another, or put forward any assumptions about what the women would or should do. It added: ‘We were satisfied that any callers to the advice line would be advised about the health implications of any intervention or procedure which might be appropriate for her, in consultation with a qualified and regulated healthcare professional.’

The ProLife Alliance said it was outraged at the ASA’s decision. A spokeswoman said: ‘It is preposterous to assert that the ad was not misleading’.

Marie Stopes abortion advice TV ad complaints rejected. BBC News Online, 4 August 2010

ASA Adjudication on Marie Stopes International. Advertising Standards Authority, 4 August 2010

Marie Stopes’s Abortion Advertising Campaign: update. ProLife Alliance, accessed 12 August 2010.

UK: Abortion provider under fire for providing sexual health services to staff

The Mail on Sunday claims that Marie Stopes International is offering free abortions for staff as a ‘perk of the job’.

Marie Stopes International offers employees, their partners and children free abortions as part of its benefits package - which also includes cheap gym membership, reduced rates at theme parks and an annual health check for £10, the Mail on Sunday reported.

According to the organisation’s website, staff who work for Marie Stopes can claim a range of sexual health services free from their employer, including testing for sex­ually transmitted diseases such as HIV and syphilis. The website says: ‘Team members, their partners and dependants will be able to access MSI’s core services... without charge.’ It lists services such as sterilisation, testing for HIV and sexual infections, ultrasound, family planning and abortion.

The NHS offers free abortions, the Mail on Sunday notes, but some women prefer to pay privately to terminate as quickly as possible.

Josephine Quintavalle, of the Pro-Life Alliance, said: ‘Never famous for its sensitivity, Marie Stopes recently shared controversial TV advertising time with a selection of beer brands, rival supermarkets, hair products and well-known confectionary bars. So it is not surprising this crass organisation equates free abortions with gym membership as appropriate consumer perks for employees and their families.’

One worker at Marie Stopes told The Mail on Sunday: ‘What you get as a benefit of working here is access to medical services, not just abortions. It’s because we are a medical services provider that people who work here get access to those services. It’s not odd. It’s there if you have got a need. It’s a positive thing.’

Ann Furedi, chief executive of BPAS, said: ‘I wouldn’t post it as a perk of the job, but if we had staff requiring our services, we’d waive our fees. Unplanned pregnancy can happen to anyone, even those working in abortion services.’

Tracey McNeill, vice-president of UK and Western Europe Marie Stopes International, said: ‘As with the majority of health service employers, we subsidise a full range of health services for our staff including well-men and well-women health checks, contraception, cervical cancer screening, unplanned pregnancy advice and abortion. As a responsible employer, Marie Stopes International promotes a full range of sexual health information and contraception to our employees.’

Marie Stopes International added that it had been offering the free sexual health services to staff, including abortions, for a decade but it did not keep records to say how many workers had taken advantage of the benefit.

Anger as abortion provider Marie Stopes offers staff free terminations as ‘job perk’. Daily Mail, 8 August 2010

UK: Government consultation on family planning in the developing world

The UK Government is to ‘put family planning at the heart of its approach to women’s health in the developing world’ in an attempt to reduce the persistently high number of women who die in pregnancy and childbirth, the Secretary of State for International Development has announced. 

The new approach will see a significant increase in the availability of family planning to meet the demands of some of the world’s poorest women, states the media release from the Department for International Development.

The media release also states that there are currently 215m women in the developing world who would like to delay or avoid their next pregnancy, but do not have access to modern family planning methods.  Increasing access could prevent up to 30 per cent of all maternal deaths and 20 per cent of newborn deaths.

This approach – including tackling head-on the unmet need for family planning – marks a significant shift in the UK’s approach to addressing the most off-track Millennium Development Goal: to improve maternal health.

Speaking at the launch of a wide ranging public consultation, ‘Choice for women – wanted pregnancies, safe births’, which will seek the views of development experts, health professionals and the public on the proposed direction of the DFID’s policy, International Development Secretary Andrew Mitchell said:

‘It is clear why reproductive and maternal health is the most off-track of all the Millennium Development Goals. The international community has failed to assist millions of women by ignoring the complexities of why at least a third of a million women in the world’s poorest countries die during pregnancy and childbirth each year. For too long we’ve been trying to tackle the issue with one hand tied behind our backs. DFID will now have an unprecedented focus on family planning, which will be hard-wired into all our country programmes.’

DFID’s new consultation on reproductive, maternal and newborn health highlights a range of issues including family planning, adolescent fertility, unsafe abortion, antenatal care, and skilled care at delivery. DFID claims that failure to address these issues contributes to up to 1,000 women dying needlessly in pregnancy and childbirth every day.

New focus on family planning to reduce deaths in pregnancy and childbirth. Department for International Development, 27 July 2010.

Public consultation: ‘Choice for women – wanted pregnancies, safe births’. The consultation will close on 20 October 2010. 

India: A comparison of two regimens of misoprostol for second trimester medical abortion

The objective of this study was to compare the efficacy and side-effects of two regimens of vaginal misoprostol for second trimester voluntary medical termination of pregnancy (MTP) according to the MTP Act of India. From Tropical Doctor.

A randomised trial was conducted in 185 women from January 2007 to September 2008.

Women in group 1 were given vaginal misoprostol 400 microg every 6 h for a maximum of four doses. Women in group 2 were given vaginal misoprostol 400 microg every 12 h for a maximum of four doses. The primary outcome measure was induction abortion interval. Secondary outcome measures were success rate, side-effects and completeness of procedure.

Results were calculated applying Fisher’s exact test, chi-square test, Z test and calculating the P value using an alpha level of 0.05 for Type I error. The mean induction abortion interval in group 1 (12.59 h) was significantly shorter (P < 0.001) than that in the group 2 (16.41 h). The percentage of women who achieved successful abortion within 12 h in group 1 (56.52%) was also significantly higher (P = 0.00005) than that in group 2 (25.80%). The incidence of side-effects was comparable and not clinically serious.

The authors concluded that the regimen of vaginal misoprostol 400 microg every 6 h was more effective than the regimen of misoprostol every 12 h in medical termination of second trimester pregnancy.

Department of Gynaecology & Obstetrics, NRS Medical College, Kolkata, 138 AJC Bose Road, Kolkata-700014, West Bengal, India.

A comparison of two regimens of misoprostol for second trimester medical termination of pregnancy: a randomized trial. Chaudhuri S, Banerjee PK, Mundle M, Mitra SN. Tropical Doctor. 2010 Jul;40(3):144-8.

USA: Immediate postabortal insertion of intrauterine devices

From the Cochrane Database of Systematic Reviews.

The authors note that insertion of an intrauterine device (IUD) immediately after an abortion has several advantages. The woman is known not to be pregnant. Many clinicians refuse to insert an IUD in a woman who is not menstruating. After induced abortion, a woman’s motivation to use contraception may be high. However, insertion of an IUD immediately after a pregnancy ends carries risks, such as spontaneous expulsion due to recent cervical dilation.

The study’s objectives were to assess the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion. The authors searched MEDLINE, CENTRAL, POPLINE, EMBASE, ClinicalTrials.gov, and ICTRP. They also contacted investigators to identify other trials.

The authors sought all randomised controlled trials with at least one treatment arm that involved IUD insertion immediately after an induced abortion or after curettage for spontaneous abortion, and identified 11 trials which described random assignment. The authors evaluated the methodological quality of each report and abstracted the data. We focused on discontinuation rates for accidental pregnancy, perforation, expulsion, and pelvic inflammatory disease. They computed the weighted average of the rate ratios, and computed relative risks (RR) with 95% Confidence Intervals (CI).

The main results found three trials randomised to immediate or delayed insertion. One showed no significant differences. Meta-analysis of two showed use of levonorgestrel-releasing intrauterine system or CuT380A was more likely for immediate versus delayed insertion (RR 1.18; 95% CI 1.08 to 1.28). Another trial randomised to the levonorgestrel IUD or Nova T; discontinuation rates due to pregnancy were 0.8 and 9.5, respectively. Sub-analysis showed higher expulsion rates for postabortal than interval insertions (levonorgestrel: 2.8 versus 6.8; Nova T: 3.0 versus 8.3).

Seven trials examined immediate insertion. From meta-analysis of two multicenter trials, pregnancy was less likely for the TCu 220C versus the Lippes Loop (RR 0.38; 95% CI 0.20 to 0.72) as was expulsion (RR 0.51; 95% CI 0.30 to 0.88). Estimates for the TCu 220 versus the Copper 7 were 0.52 (95% CI 0.36 to 0.77) and 0.58 (95% CI 0.39 to 0.87), respectively. In other work, adding copper sleeves to the Lippes Loop improved efficacy (RR 3.82; 95% CI 1.41 to 10.36) and reduced expulsion (RR 3.37; 95% CI 1.65 to 6.90).

The authors concluded that insertion of an IUD immediately after abortion is safe and practical. IUD expulsion rates appear higher than after interval insertions. However, IUD use is higher at six months with immediate than with interval insertion.

Behavioral and Biomedical Research, Family Health International, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709.

Immediate postabortal insertion of intrauterine devices. Grimes DA, Lopez LM, Schulz KF, Stanwood NL. Cochrane Database of Systematic Reviews. 2010 Jun 16;6:CD001777.

UK: Government to abolish health watchdogs

The Health Protection Agency and the Human Fertilisation and Embryology Authority are to be axed under reforms.

The HPA and the HFEA are among the eight or ten of the 18 ‘arms-length bodies’ that will go or be merged with other organisations, BBC News Online reports.

Health Secretary Andrew Lansley said the aim was to save costs and cut bureaucracy in the NHS. He stressed that essential work would be moved to other bodies.

Most of the changes, designed to save £180m over the next few years, apply to England only, although some arms-length bodies cover the whole of the UK. The changes are laid out in the the document Liberating the NHS: Report of the arms-length bodies review.

Mr Lansley said: ‘Over the years the sector has grown to the point where overlap between organisations and duplication of effort have produced a needless bureaucratic web. By making sure that the right functions are being carried out at the appropriate level, we will free up significant savings to support front-line NHS services.’

The Human Fertilisation and Embryology Authority will continue to function for the time being, but will transfer its functions by the end of the current Parliament between a new research regulator, the Care Quality Commission, and the Health and Social Care Information Centre.

The Health Protection Agency, which has been responsible for responding to public health hazards such as bird flu and swine flu since 2003, will hand over its workload to the Secretary of State as part of the new Public Health Service.

The National Patient Safety Agency will also go. Patient safety will instead be overseen by the National Commissioning Board, while its research and ethics functions will move elsewhere.

Some applaud the changes, the BBC reports. The National Treatment Agency for Substance Misuse, which is to go, has been heavily criticised for spending billions of pounds on schemes with little proof they work.

But opponents say closures could compromise patient and public safety.

Vivienne Nathanson, head of science and ethics at the British Medical Association, questioned the abolition of the HPA saying: ‘Public health messages are often more effective coming from this agency than the Government.’

Health watchdogs ‘are to be axed’. BBC News Online 26 July 2010

Liberating the NHS: Report of the arms-length bodies review. Department of Health, July 2010

Motherhood, abortion and parenting culture

At a recent conference, academics from the UK and USA came together to discuss new challenges to women’s autonomy. Jennie Bristow reports.

The seminar ‘Pregnancy and pregnancy planning in the new parenting culture’, hosted by the University of Kent in June 2010, provoked a number of stimulating discussions on the following themes:

-- Abortion and reproductive decision-making in a culture of ‘intensive parenting’;
-- Assisted conception and the limits of choice;
-- The pregnant woman’s autonomy in an era of increasing lifestyle surveillance and sensitivity to fetal harm;
-- Changing ideas about motherhood and fatherhood.

Dr Ellie Lee, convenor of Parenting Culture Studies and Pro-Choice Forum, opened the conference by welcoming the speakers to the event, many of whom had travelled from the USA and are at the forefront of groundbreaking research on pregnancy and abortion. This event sought to examine the way that contemporary assumptions about parenting shape the context of pregnancy and abortion, and how such assumptions give new grounds for the surveillance and regulation of individuals’ reproductive decisions.

Rachel Jones, Senior Research Associate at the Guttmacher Institute in New York, gave a presentation on abortion decision-making in a culture of ‘intensive motherhood’. Jones challenged the assumption that women have abortions because they don’t want children, and also the ‘pro-choice assumption’ that the woman having an abortion and the woman carrying a pregnancy to term is ‘the same woman at a different stage in her life’. In fact, 61 per cent of those having abortions in the USA already have at least one child. Twenty-three per cent of those under 20 years of age are mothers, and 10 per cent had a baby in the past 12 months. Jones cited research by some colleagues indicating that the most common reason given for abortion was that children ‘would dramatically change my life’.

The Guttmacher Institute study that Jones discussed was a qualitative study of 38 women at four different abortion providers in the USA. Three quarters were mothers, and about half were at or below the poverty line. When discussing their reasons for seeking abortion, women talked about a number of issues. Their ability to care for their other children emerged as a strong theme: one woman had severe morning sickness, which felt impeded her ability to play the mothering role she wanted to in relation to her other children; another young respondent already had three children and lacked the financial resources to have a fourth child.

Mothers discussed health – their own, and that of their children – and how this related to their maternal obligations. Jones remarked upon how, even when women talked about their own health problems, it was in the context of bringing up the children they already had. Women talked about the ideal conditions of motherhood as framing their decision. Jones noted that this included both the ‘real and perceived’ disadvantages of having a child in their situation. For example, one unmarried woman with no children said that she couldn’t give her child ‘everything in the world’ – expressing the idea that total devotion to motherhood is necessary before embarking on the process.

Respondents to the Guttmacher study also raised worries about maternal and fetal health – they talked about drugs, smoking, or failing to take prenatal vitamins to express concerns that they were not ideally positioned to carry this pregnancy to term. Adoption was an issue brought up, unprompted, by nearly one in four interviewees, but in the context that to adopt would be unrealistic. Jones suggested that this expressed the idea that if you have a child, it is your responsibility to take care of it – how would you know that somebody else could do that?

In conclusion, Jones noted that most women who have abortions are mothers, and that both ideas about, and the reality of, motherhood influences women’s abortion decisions. Some women used ‘anti-choice’ language to discuss their abortions, and were sad about the decision – but they nonetheless thought that they and their families would be better off as a result of the abortion. Jones suggested that pro-choice advocates need to work to achieve better social supports for motherhood, and for parents, and to use language that speaks to women’s experiences. She also suggested that attempts to increase adoption are not going to impact upon the abortion rate. 

Danielle Bessett PhD of Ibis Reproductive Health gave a paper on ‘Pregnancy after abortion: women’s experiences of a stigmatised reproductive career’. The context of Bessett’s research is one in which 52% of US women who have abortions plan to have children in the future, and one in three women have abortions. She noted that neither of the notation systems for recording women’s obstetric history - GPA (gravida/para/abortus), and TPAL (term births, preterm births, abortions, living children) – separates between the sequence of events. Past reproductive events often re-emerge in prenatal care, and Bessett argued for a more dynamic approach to understanding this. 

Bessett discussed women’s reproductive careers in terms of the way that women’s relationship to reproductive experiences changes over time, and in relation to previous and anticipated reproductive events. She said she had been struck by the way that women talked about previous abortions while they were carrying a wanted pregnancy. One third of women interviewed reported having terminated a previous pregnancy, and women described their abortions differently at different stages.

Abortion emerged as quite distinct from the current pregnancy. Bessett noted that some of the women may have even forgotten about a previous abortion, and that it was sometimes thought of in terms of a lifestyle choice rather than a medical problem. Some women articulated feelings of regret and fear about the repercussions of abortion upon their current pregnancy – for example, illness or disability of the fetus – in terms that Bessett described as religious or ‘supernatural’. However, she stressed that these responses were not consistent with what has sometimes been described as ‘post abortion syndrome’ – the women weren’t exhibiting signs of mental illness, but they were describing their experiences in a discourse of religiosity.

Across both patterns of responses – those women who appeared to regret previous abortions, and those who did not – disclosure of a prior abortion was understood by women to affect their treatment in prenatal care and during the birth. Bessett concluded that women’s reproductive histories can shape their experiences and how they feel they are treated by others. It may be, she said, that women are not articulating a stigma attached to abortion but something else – but, she said, we don’t know what this ‘something else’ is until we interrogate it.

Evelyn Mahon, senior lecturer in sociology at Trinity College, Dublin, gave a presentation titled ‘Is there ever a good time to have a child?’ – a title which emerged from three different studies she has conducted over the past 20 years. Mahon discussed her research on women and ‘crisis pregnancy’ in Ireland, which examined factors that influenced women to have abortions. The data showed that a crisis pregnancy was socially constructed – that women who had abortions tended to be young, single and unemployed. Adoption was a major policy until the 1970s, she explained, and most illegitimate births were adopted. The sociological question this raised was, if everybody is doing one thing and abortion is seen as so awful, why do people do it?

The major findings of Mahon’s study included the experience and meaning of stigma. Stigma is about a lot of things, she explained: the negativity attached to premarital sex and single motherhood meant that the parent and child would be stigmatised. She noted that when women gave babies up for adoption, the effect was the same as that of abortion: namely, the idea that the baby was gone. In addition to stigma, Mahon talked about women’s unreadiness to have a child, which included not being able to cope financially.

Mahon went on to discuss some of the social shifts that have taken place over recent years, particularly in relation to Ireland’s economic development. Irish women have internalised ideas about the importance of education and work, and also certain ideas about the needs of the child. For example, the two-parent family has become an internalised model, and those women seeking abortion couldn’t conceive of adoption. There are new patterns of reproduction emerging, around ideas about the age at which women should have their first birth, the importance of first establishing a relationship with a sexual partner, and women’s attempts to define their own lives.

A presentation by Professor Kristin Luker, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology at the University of California, Berkeley, discussed ‘Abortion and the politics of motherhood revisited’. She began by examining the history behind abortion rights on the USA, arguing that abortion held together the gender and sexual regime – but since 1964 it changed dramatically.

The shift came about because of a combination of factors: technological change, with the Pill becoming the most popular contraceptive; ideological change, coming from the civil rights, women’s, and the student movement; and legal change. Luker highlighted the 1965 case Griswold v Connecticut, in which the Supreme Court ruled that a state’s ban on the use of contraceptives violated the right to marital privacy, as a key moment: while Roe v Wade in 1973 got all the publicity, argued Luker, Griswold had done much of the ‘heavy work’. Luker explained that Roe v Wade brought the birth of the pro-life movement: what mobilised people was not abortion, so much as the idea that the unborn child is not really a person. 

Luker discussed the dramatic changes to women’s lives brought about by the legalisation of abortion in Roe v Wade – illustrated by the increase of women into the professions. This changed the context in which decisions were made, and public opinion started to question the idea that women should leave running the country to men. However, while some women were positioned to take advantages of the changes, others were not. The option of abortion immiserated women for whom motherhood was the best job they could do. Luker suggested that women who were less educated or positioned to take advantage of equality are more likely to appreciate a gendered world, in which a housewife had a certain status.

Luker has famously argued that abortion divided women along lines of the meaning of motherhood. In recent years, she has also noticed the significance of postponing of motherhood, and changes in the status of marriage, which, she suggested, is now becoming ‘a luxury good’. Luker discussed what has been termed the ‘second demographic revolution’, with the decoupling of marriage and motherhood – the two are no longer seen as sequential.

In a session on ‘reproductive technology in an age of intensive parenthood’, Martin Richards, Emeritus Professor of Family Research at Cambridge University, discussed the question of ‘Choice or eugenics?’ Richards described the history of antenatal screening, noting that the first genetic clinic was established in 1946, for couples who had a child with a genetic disorder – the main issue was ‘recurrence’, and couples would often decide to have no further children. Richards argued that the culture in which the clinic operated was one of reform eugenics, and its aims were not controversial at the time.

Richards went on to explain that with the end of eugenics in the 1970s, such ideas became ‘unmentionable’. There was a shift from the belief in self-sacrifice for the common reproductive good to individualistic reproductive autonomy. Health professionals stopped giving advice in this area and instead provided information and ‘non-directive counselling’. He posed the question of whether this represented an end of the genetic clinic, or its rebirth in a culture of choice?

Moving on to antenatal screening today, Richards discussed the recent attempt to repeat Ann Oakley’s study of maternity care in the mid-1970s, when two-thirds of scans were dating scans. The 2009 study found that all women had scans at 11 weeks and an anomaly scan at 22 weeks. One third of women also had private scans, for a variety of reasons – both medical and to gain a clear image of the fetus. He pointed out that women are seeking antenatal scans – they are not being imposed upon them.

Richards discussed other screening programmes that are available today, including those which are directed towards specific groups at particular risk of certain disorders, and new diagnostic tests, including non-invasive tests that use blood samples to look at Free Fetal DNA. The lesson from history, Richards argued, is that ‘people do what they can do’ in utilising such technologies. He concluded by noting that there are more and more opportunities for testing, and only four possible ways to exercise choice: choice of sexual partner, termination of pregnancy, IVF and embryo selection, or gene therapy.

Julie McCandless, lecturer in law at Oxford Brookes University, discussed ‘What is “supportive parenting”? The new “Welfare of the Child” clauses in the Human Fertilisation and Embryology Act (2008)’. This was based on work she has conducted with Professor Sally Sheldon on the legislative backdrop to the HFE Act 2008 – a flagship piece of legislation passed by the New Labour government. McCandless noted that this legislation raised a number of controversial issues, the foremost of which was the removal of the ‘need for a father’ in the provision of fertility treatment, and the replacement of this clause with the need for ‘supportive parenting’.

McCandless discussed the media reportage of this shift, which focused on the idea that ‘no fathers are required’, and asked why it excited so much attention. Although this was represented as a major change, it was not necessarily so significant in terms of clinical practice – the Human Fertilisation and Embryology Authority (HFEA)’s code of practice has been interpreted increasingly liberally. ‘All the fuss’ can be explained, argued McCandless, through ‘a number of conflations’.

This is a clause with a long history, and the ‘need for a father’ initially represented a compromise with Conservative MPs who wanted to restrict ARTs to married couples. Also significant was how agendas were set in the process of legal reform. McCandless noted that the House of Commons Science and Technology Committee had recommended the removal of the ‘welfare of the child’ clause – initially, the issue was the clause itself. By the time the debate came to Parliament, some compromise was needed again. The simplicity of the phrase, and the way the deletion of the ‘need for a father’ clause became the focus of societal anxieties was another issue – the discussion of the need to have an explicit mention of fatherhood relates to broader anxieties around fatherhood, and the family.

In a session titled ‘Extending parenting backwards? Pregnancy and pre-pregnancy in contemporary context’, Elizabeth Mitchell Armstrong, Associate Professor of Sociology and Public Affairs, Princeton University, posed the question: ‘Do happier pregnancies make healthier babies? Stress and the medicalisation of maternal emotion’. Armstrong listed the wide range of adverse effects associated in contemporary discourse with stress in the mother, from pre-term birth to excessive crying and even schizophrenia.

Armstrong noted that there many hypothesised mechanisms by which stress might affect the fetus. But there is remarkably little evidence that stress has any of the effects upon the fetus that dominate media discussion of this issue. In discussing why concerns about maternal stress this idea has taken hold of today’s imagination, Armstrong linked the ‘scientific’ maternal stress discussion with the historical (palpably unscientific) notion of maternal impressions: the idea that something the woman sees or tastes can leave a direct mark on the fetus, with the effect that ‘strawberry’ birthmarks were understood as a result of a mother’s craving, for example.

Armstrong argued that these beliefs continue today. Despite the pseudo-scientific character of the maternal stress discussion, the responsibility for reducing stress is placed squarely on women’s shoulders, contributing to the regulation of pregnant women’s bodies and behaviour.

Cynthia Daniels, Professor of Political Science at Rutgers University, gave a paper titled ‘Policing pregnancy: The politics of fetal risks’. Daniels argued that reproductive politics in the USA has traditionally focused on abortion, but in recent years this has shifted to the management and control of the pregnant body. The most visible campaigns around pregnancy have been around alcohol use, as in the slogan ‘a pregnant woman never drinks alone’. Yet what we are now seeing is how ‘information’ about fetal development extends is backwards to even the point where ‘sexually active women who are not using contraception’ need to be thinking about how their behaviour might affect potential children.

Daniels noted that there have been 200 prosecutions of pregnant women since 1980 in the USA. Fifteen US states, for example, consider substance abuse in pregnancy to be child abuse, and 33 require health care professionals to report to welfare authorities the suspected use of alcohol or drugs in pregnancy. In some cases where women have suffered stillbirth, they have been convicted of homicide for using cocaine in pregnancy. In conclusion, Daniels noted that there was a presumed exclusive responsibility of women for fetal health/harm: despite the sensitivity of the male reproductive system to environmental effects and toxins.

These presentations were followed by a panel discussion with Frank Furedi, Professor of Sociology at the University of Kent, and Janet Golden, Professor of History at Rutgers University. Furedi noted some distinctive new features of the moralising imperative towards pregnancy. One is an ambiguity in the discourse about pregnancy: it is both celebrated yet problematised, to the extent that it becomes a focus for ‘joined up fear-mongering’ and regarded as an opportunity for social intervention. He argued that when fetal rights are elevated, human subjectivity, in terms of consciousness and experience, is flattened out. Picking up on Daniels’s emphasis upon the sensitivity of the male reproductive system, Furedi cautioned that there was a danger in medicalising male reproduction in the same way as female reproduction.

Janet Golden provided a historical perspective on these debates. She noted that the idea that we want ‘happy babies’ is a very modern secular view – society used to want fearful babies, ‘trembling before God’. She pointed to the limits of the maternal stress discourse in relation to the anti-abortion literature: nobody says ‘okay, well, if you’re stressed by pregnancy, why don’t you have an abortion?’ Golden also cautioned about the tendency to rely upon animal studies to make claims about maternal behaviour, which can then become the basis for social policy.

The ensuing discussion raised issues to do with how new and culturally specific concerns about the fragility of the fetus are: a concern that did not exist until the 1960s, when the Thalidomide tragedy indicated the extent to which drugs could cross the placenta. The ‘duality of pregnancy’ was discussed, as something that is both sacred and profane, that we revere and are revolted by. A pregnancy is seen both as fragile and hard to achieve, and in other instances hard to get rid of. A key question was raised about how reproductive needs could be put on the agenda without extending the power of state surveillance, and the problems inherent in the idea of ‘the public pregnancy’, which now seems to dominate the debate.

A session examining ‘fatherhood and parenting culture’ began with a paper from Tina Miller, Reader in Sociology at Oxford Brookes University, on ‘Men and “bonding”: fathers’ expectations in the antenatal period’. Discussing findings from a recent study exploring fatherhood, Miller argued that there were clearly dominant discourses about ideal, ‘involved’ fathering, which include preparing appropriately for fatherhood by accessing information, attending antenatal classes, and so on - but that there remains a recognition amongst fathers that they don’t have the same emotional involvement as mothers.

Jonathan Ives, Lecturer in Behavioural Science and Heather Draper, Reader in Biomedical Ethics, from the Centre for Biomedical Ethics at the University of Birmingham, presented a paper titled: ‘Should we strive to involve men in a meaningful way during pregnancy? Rethinking men’s involvement in antenatal care’. They noted that men’s involvement in antenatal care is part of a wider narrative around the modern father, demanding physical and emotional presence overlying an economic and social responsibility. There are tensions here: the implicit breadwinner role is always the bottom line.

In examining the ways in which the involvement of fathers in antenatal care could be justified in ethical terms, Ives and Draper suggested that it is not clear that this is the best way of fostering fathers’ engagement. Furthermore, overt attempts to ‘involve’ men may run risk of creating the father as a passive bystander, and may make women feel obliged to engage a partner, even if they don’t want to.

In response to these papers, Mary Ann Kanieski, Assistant Professor of Sociology at Saint Mary’s College, Notre Dame, Indiana, argued that in terms of medicalised parenting, one of the most pervasive trends is the intensification of fatherhood. She asked why fatherhood should today be constructed in relation to child well-being, rather than as something enjoyable, and suggested that the discussion of mothers’, fathers’, or children’s interests misses the concept of family, in which the interests of all members must be balanced.

The third session examined the current advice to abstain from alcohol during pregnancy, offering perspectives from the USA and from Britain. Janet Golden, Professor of History at Rutgers University and author of the book Message in a Bottle: The Making of Fetal Alcohol Syndrome, focused on the construction of Fetal Alcohol Syndrome (FAS), from the emergence of this as a concern in the USA in the early 1970s. Golden described the process of the politicisation of drinking in pregnancy, and questioned the extent to which scientific evidence about the teratological effects of alcohol on the fetus could explain the ‘crusade to warn’ all pregnant women, but with a particular focus on ethnic minorities, about their drinking behaviour.

A presentation by Pam Lowe, Lecturer in Sociology at Aston University, discussed the ‘migration’ of the Fetal Alcohol Syndrome problem from the USA to the UK, in the form of a much broader range of disorders grouped as Fetal Alcohol Spectrum Disorder (FASD). Until 2000, very little attention was paid to FAS in the UK, but it emerged as a problem around the activities of particular claims-makers and lobby groups.

Interest in this issue peaked in 2007, when the Department of Health and the National Institute of Clinical Excellence produced slightly different recommendations on alcohol consumption during pregnancy. The recommendations were later brought in line with one another: advising no alcohol consumption at all for pregnant women or those trying to conceive, despite an official recognition that this warning was not based on scientific evidence. Lowe argued that in the UK, the message straightaway took the form of a ‘democratised threat’, presenting all women who as ‘at risk’. This is another example of the trend towards the ‘public fetus’ – broader aspects of motherhood are screened out.

The panel discussants were Elizabeth Armstrong of Princeton University and Pat O’Brien, Consultant and Honorary Senior Lecturer in Obstetrics and Gynaecology at University College Hospital London, and spokesperson for the Royal College of Obstetricians and Gynaecologists (RCOG). Armstrong talked about the ‘globalisation of public health policy, especially around drinking during pregnancy’, and saw this within a trend towards the individualisation of responsibility: abstinence messages are not about providing community level solutions, but about convincing individuals to act in a particular way. She pointed to the paradox that a woman is constructed as the ultimate protector of the fetus, yet she and her body are also constructed as the greatest threat to fetal well-being

Pat O’Brien noted that FAS and FASD are not the same thing: FAS is a definite diagnosis, while FASD is so uncertain that ‘people who are searching for reasons for misfortune can use FASD, as it fits the bill with a range of symptoms’. He questioned whether abstinence guidelines would reduce the incidence of FAS and argued that abstinence messages can actively cause harm: by ‘crying wolf’, based on unsound evidence; and by making good mothers who have drunk in previous pregnancies according to previous guidelines ‘feel terrible’.

Additional reporting by Charlotte Faircloth.

This two day seminar was organised by Parenting Culture Studies and the Kent Centre for Law Gender and Sexuality, and supported by BPAS and the Economic and Social Research Council. The full programme is available here.

The abstracts for the seminar are available here, and the slides can be viewed here.

UK: GPs to gain commissioning powers

GP practices are set to be handed responsibility for most health services under ministerial plans for a radical shake-up of the National Health Service in England.

Local trusts and strategic health authorities will be sharply scaled back to make way for their new role, BBC News Online reports.

Health Secretary Andrew Lansley believes GPs are best placed to understand patients’ needs and to decide where money should be spent. But there are concerns GPs may not have the skills or will to take on the role. Others have questioned how they would be held accountable.

The NHS budget currently stands at £100bn a year. About 80% of this is given to local health managers working for 152 primary care trusts, which in turn commission services for their areas. The plans involve setting up groups of practices which would work together in consortia, then buy in management skills, possibly from people doing the same job for existing primary care trusts.

The consortia would take charge of billions of pounds of funds for mental health, hospital and community services.

The White Paper, Equity and excellence: Liberating the NHS, sets these proposals out under the heading ‘Autonomy, accountability and democratic legitimacy’:

The Government’s reforms will empower professionals and providers, giving them more autonomy and, in return, making them more accountable for the results they achieve, accountable to patients through choice and accountable to the public at local level:

-- The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.
-- The Government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia.
-- To strengthen democratic legitimacy at local level, local authorities will promote the joining up of local NHS services, social care and health improvement.
-- We will establish an independent and accountable NHS Commissioning Board. The Board will lead on the achievement of health outcomes, allocate and account for NHS resources, lead on quality improvement and promoting patient involvement and choice. The Board will have an explicit duty to promote equality and tackle inequalities in access to healthcare. We will limit the powers of Ministers over day-to-day NHS decisions.
-- We aim to create the largest social enterprise sector in the world by increasing the freedoms of foundation trusts and giving NHS staff the opportunity to have a greater say in the future of their organisations, including as employee-led social enterprises. All NHS trusts will become or be part of a foundation trust.
-- Monitor will become an economic regulator, to promote effective and efficient providers of health and care, to promote competition, regulate prices and safeguard the continuity of services.
-- We will strengthen the role of the Care Quality Commission as an effective quality inspectorate across both health and social care.
-- We will ring-fence the public health budget, allocated to reflect relative population health outcomes, with a new health premium to promote action to reduce health inequalities.

The NHS budget has been protected by the coalition government, and is not subject to the severe cuts of other Whitehall departments, BBC News Online reports. But the health service has been told to save up to £20bn by 2014 to help it cope with the ageing population, rising drug prices and lifestyle changes such as obesity.

The move to having GP consortia controlling spending has long been championed by Mr Lansley - and in recent months the British Medical Association has indicated it is open to working with the government on the idea.

Dr Laurence Buckman, chairman of the BMA’s GPs committee, said: ‘We will have to see the details, but there is certainly a willingness to look at this.’ However, he also warned that the process should not be rushed, as this would risk a loss of focus.

Professor Steve Field, chairman of the Royal College of General Practitioners, said: ‘From what we can glean, the direction of travel is the right one.’

There have been other reports of opposition to the plans amongst GPs, with the website Healthcare Republic reporting: GPs and practice managers split on health White Paper.

NHS shake-up ‘hands funding powers to GPs’ BBC News Online 9 July 2010

Equity and excellence: Liberating the NHS. Department of Health, July 2010.

NHS White Paper 2010 - news and analysis. Healthcare Republic, July 2010.

Q&A: The NHS shake-up. BBC News Online, 15 July 2010

‘Always glad to receive it’

Results of the Abortion Review Readers’ Survey 2010. 

Many thanks to those of you who took part in our 2010 Readers’ Survey. We received dozens of responses from readers around the world, working as doctors, nurses, sexual health advocates, academics, policymakers, journalists and students.

Many respondents had been receiving the publication for several years, and commented that they continue to find Abortion Review both professionally useful, and personally interesting. Readers’ comments provided some valuable feedback as to what Abortion Review does well, and suggestions about other things we could do. We will take all of these ideas into account when developing the publication over the next year.

All of the survey responses were entered into a draw. Congratulations to commissioning manager Richard Gill, who won the £50 Amazon voucher.

Abortion Review is published both in print and online. The online edition provides a bank of news and commentary, updated frequently and archived in full. To receive monthly updates about what’s new on Abortion Review, please join our free mailing list: follow the link here, add your email address, and click on the confirmation email when it arrives in your inbox.

The print edition is published quarterly, providing a neat digest of the main developments in abortion news. The print editions can be downloaded as .pdf documents here. To receive the print edition through the post, please email .

Below are some of the comments our readers have made about Abortion Review. If you have any further ideas, do please email me at .

Yours,

Jennie Bristow
Editor, Abortion Review

Readers’ comments

“It’s good to have a publication that brings all the news together - as it is often difficult to find in other media.”

“Excellent source of information.”

“It’s great. I have no complaints and, rather unimaginatively, no suggestions. I actually would rather there NOT be a comments facility for articles, which is weird I know, but I like the peace and quiet of AR in that regard. There’s so much commenting going on, especially about abortion and much of it simply going over and over the same ground.”

“Always prompts discussion and offers balanced arguments. Articles usually timely and relevant.”

“Always glad to receive it, good publication.”

“Not just a ‘newsletter’: Abortion Review does tell us something. Give us one excellent article and lots of small bits of info/events we don’t know about.”

“Good publication and global!”

“I use the paper version for our staff information folder - helping keep them up to date.”

“A printed copy is always very helpful for reference.”

“I have received your review for some years and always read it.”

“Thanks for doing what you do!”

UK: Warnings over unregulated sperm donation websites

An investigation by The Times (London) has claimed that unregulated ‘fertility’ websites that put their members in touch with sperm donors for a fee are exploiting vulnerable women and risking users’ health and finances.

The Times also claims that such sites, which enable people including single women and lesbian couples to obtain sperm outside of the regulated market, are being used by men searching for ‘no-strings unprotected sex’.

A spokesman for the Human Fertilisation and Embryology Authority said: ‘If you use a site that does not direct you to a licensed clinic, you put yourself at risk that the sample you receive is neither safe nor screened and that the donor is not who they say they are.’

The regulator also warns that donors who donate sperm via these sites rather than at licensed clinics will be the legal fathers of any children born to single women or unmarried couples and may be liable for child support, The Times reports.

Natalie Gamble, of Gamble and Ghevaert, a firm of solicitors that specialises in fertility law, said that the legality of the sites was a grey area. ‘What is illegal is procurement of gametes [sperm and eggs]. It comes down to the definition of what procurement is. Putting sperm in the post would seem to be clear. Less clear is helping individuals to make contact with one another.’

Dr Allan Pacey, senior lecturer in andrology at the University of Sheffield, said that the sites profited from the relative expense of licensed clinics — which charge about £800 for frozen sperm and one insemination cycle — and from a shortage of sperm at clinics now that children born to donor sperm are allowed to contact their natural father when they are 18.

Dr Pacey cautioned that sperm obtained using the sites is not adequately screened, so puts the recipient at risk of blood-borne and sexually transmitted diseases, including HIV. It may also carry genetic disorders such as Down’s syndrome. He said that the risk was even greater if some donors have predatory intent. ‘If a man wants to impregnate the South East, that ups the risk that he will be in poor sexual health.’

Dr Pacey added: ‘A licensed clinic will run tests before taking samples and again six months after the last sample was taken and frozen. Sperm can only be used after this final check.’

In a commentary on the article, Mark Henderson, The Times‘s science editor, wrote that the advent of such websites ‘is not only the result of a grey area in new laws that were supposed to put a stop to unregulated sperm donation, but is also a symptom of a national crisis in sperm donation that has emerged since the last Government removed donors’ rights to anonymity in 2005.’

Henderson continued:

‘The continuing shortage has prompted many people who need donated sperm to conceive to try unlicensed online services, or to turn to “fertility tourism”.

‘The gamete gap has also stirred fresh debate over payments to egg and sperm donors, who can at present receive only expenses up to £250. Donors in countries such as Spain and the Czech Republic can receive sums up to three times higher, while the United States has an unregulated market.

‘The ban on anonymous donation is almost certainly here to stay — it is overwhelmingly supported by donor-conceived people. However, the HEFA could lift the ban on donors fathering children by more than ten women. While this is intended to prevent “accidental incest”, many scientists consider it an arbitrary rule. In the Netherlands, which has a quarter of the population of Britain, a donor can father up to 25 children.

‘More generous rules on family numbers, combined with more generous payments to donors, could certainly improve the supply of sperm. And that would be as effective a way of controlling unregulated donation services as legislation.’

Fertility websites are risking women’s health, warns regulator, by Mark Bridge. The Times (London), 16 July 2010.

The abitrary rules on payments and family numbers must be relaxed, by Mark Henderson. The Times (London), 16 July 2010.

Also read:

Banking Crisis: What should be done about the sperm donor shortage? Abortion Review, 1 July 2009

Canada: Assessment of pain after abortion relating to the use of misoprostol for cervical dilatation

The study’s objective was to compare the use of misoprostol to that of laminaria tents for dilatation of the cervix before a surgical elective abortion (EAB) during the first trimester, with regard to the pain caused (1) during insertion, for both methods, (2) immediately before the EAB, and (3) one hour after the procedure. From Journal of Obstetrics and Gynaecology Canada.

One hundred two women were recruited at Clinique de planification des naissances du Centre hospitalier universitaire de Québec, CHUL pavilion, between March 1, 2006 and March 1, 2007, for a tracking study. Fifty-three women were given 400 microg of misoprostol intravaginally, three to four hours before the EAB, and a laminaria tent was inserted in 49 women, 16 to 24 hours before the EAB. A visual analog scale was used to determine the pain score.

The results found that one hour after EAB, severe pain was reported in 6% of the participants who were given misoprostol. The pain score post-EAB was 3.8 times higher in women who were given misoprostol than in those who had a laminaria tent inserted (P = 0.004). The pain score during insertion of the dilatation method was 33 times higher with the laminaria tent than with misoprostol (P < 0. 001), and 30% of women who had a laminaria tent inserted felt severe pain.

The authors concluded that while misoprostol may increase pain after EAB in a small percentage of women, it remains an efficient, easy to use, low-cost method for dilating the cervix before an EAB. It is one of the options that may be offered to women when a pre-EAB dilatation of the cervix is required, after discussing its benefits and disadvantages with them.

Department of Obstetrics and Gynecology, Centre hospitalier universitaire de Québec, Quebec QC.

Assessment of pain after elective abortion relating to the use of misoprostol for dilatation of the cervix. Gagné A, Guilbert E, Ouellet J, Roy V, Tremblay JG. Journal of Obstetrics and Gynaecology Canada. 2010 Mar;32(3):244-53.

AR update, 7 July 2010

Why do people get pregnant (when they don’t want to be?); the science of fetal pain and the ethics of abortion; Australian attitudes to late abortion, and more ...

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This news digest is sent by email to those who have signed up to the Abortion Review Online mailing list. To join the mailing list for free, see here.

A quarterly news digest is provided in the print edition of Abortion Review. You can download the print edition for free here.

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- 1. WHY DO PEOPLE GET PREGNANT (WHEN THEY DON’T WANT TO BE)?

The 2010 BPAS annual lecture was given by Kristin Luker, the foremost American sociologist researching contraceptive use and risk taking around unplanned pregnancy in the USA.

Professor Luker argued that how individuals think about contraception, birth, pregnancy and abortion is ‘actually an enormously complicated risk analysis’. Individuals calculate the costs of contraception, the benefits of getting pregnant, the probabilities of pregnancy, and the probabilities of reversing the ‘decision’: ‘I put “decision” in quotes because it’s much too formal a word for what I think really happens’.

Individuals’ decisions are affected by a range of factiors, including the changing social meaning of sex and pregnancy, and the broader ‘politics of motherhood’. Recognising this situation raises ‘some very difficult and awkward questions’ to do with unplanned and unwanted pregnancy: ‘unplanned by whom? And more subtly, and more deeply, unwanted by whom?’

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- 2. THE SCIENCE OF ‘FETAL PAIN’, AND THE ETHICS OF ABORTION

Commentary by Stuart Derbyshire, a member of Working Party that produced the RCOG’s new reports on fetal awareness.

‘The 2010 report on fetal awareness concludes that the necessary connections for pain are not intact before 24 weeks, and so “the fetus cannot experience pain in any sense prior to this gestation”. It also concludes that fetal pain is highly unlikely after 24 weeks, both because important neural development is ongoing and because the fetus remains asleep and sedated in the womb.

‘The report stood above the political arguments about abortion and refrained from commenting on the ethics of abortion. No attempt was made to create an argument for or against abortion at any gestational age and the committee took the correct view that abortion is not a question that can be resolved by science. Science may be useful in informing the decisions of policymakers, but science cannot decide if abortion is right or wrong or whether it should be legal...’

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- 3. UK: IMPORTANT NEW REVIEW ON FETAL AWARENESS PUBLISHED

There is no new evidence to show fetuses feel pain in the womb before 24 weeks, a report by the Royal College of Obstetricians and Gynaecologists has stated.

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- 4. AUSTRALIAN ATTITUDES TO EARLY AND LATE ABORTION

A study of public opinion published in the Medical Journal of Australia has found a high level of support for access to early abortion, and little support for professional sanctions against doctors for providing terminations after 24 weeks’ gestation.

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- 5. ‘ENHANCING THE LIVES OF CHILDREN: HOW FAR SHOULD WE GO?’

A conference at the Royal Society of Medicine raised some interesting and important questions about how today’s society should view the role of genetic, chemical and behavioural techniques in shaping children’s health and behaviour. Jennie Bristow reports.

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ABORTION REVIEW UPDATES

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For news updates from the UK, see here.

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For news updates from around the world, see here. 

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For updates from the medical press, see here.

The science of ‘fetal pain’, and the ethics of abortion

Commentary by Stuart Derbyshire, a member of the Working Party that produced the RCOG’s new reports on fetal awareness. 

In 1997 the UK Royal College of Obstetricians and Gynaecologists (RCOG) produced a report on fetal awareness (1). Eleven experts examined the evidence for fetal awareness and especially concentrated on the possibility of the fetus feeling pain. The report drew a number of important conclusions, but the most salient was that the connections necessary for pain are not developed before 26 weeks and so the fetus ‘cannot be aware of sensory stimuli before that time’ .

The need to update the 1997 report arose as a consequence of the House of Commons Science and Technology Committee examining the issue of abortion shortly after the fortieth anniversary of the 1967 Abortion Act. The committee produced a report, Scientific Developments Relating to the Abortion Act 1967, and in response the minister of state for public health recommended that the RCOG review its 1997 report. Subsequently, a new committee of 12 experts, including myself, was formed to examine the question of fetal awareness. Similar to 1997, the committee paid special attention to the question of fetal pain. The final report was released on 25 June (2).

The 2010 report is a major update on the 1997 report and includes a glossary, a discussion of neurobiology and clinical practice, and information for women and parents. The 2010 report on fetal awareness is also accompanied by a second report examining termination of pregnancy for fetal abnormality (3).

Similar to the 1997 report, the 2010 report on fetal awareness concludes that the necessary connections for pain are not intact before 24 weeks, and so ‘the fetus cannot experience pain in any sense prior to this gestation’. Unlike the 1997 report, however, the 2010 report also concludes that fetal pain is highly unlikely after 24 weeks, both because important neural development is ongoing and because the fetus remains asleep and sedated in the womb.

It is worth highlighting a number of strengths of the 2010 report. Both the 1997 and 2010 reports stood above the political arguments about abortion and refrained from commenting on the ethics of abortion. No attempt was made to create an argument for or against abortion at any gestational age and the committee took the correct view that abortion is not a question that can be resolved by science. Science may be useful in informing the decisions of policymakers, but science cannot decide if abortion is right or wrong or whether it should be legal. The moral status of abortion and its legality are questions that can only be addressed via moral and political debate. The fact that the fetus does not feel pain does not negate objections to abortion based on the perceived sanctity of fetal life and it does not negate any other religious, moral or political objection to abortion either.

Unlike the 1997 report, the 2010 report does not entirely avoid the issue of how we define pain. In my opinion, this question is absolutely critical. If we define pain as the response to something painful, such as a scalpel or a needle, then it is evidently the case that the fetus feels pain from a very early gestation (around eight to 10 weeks) when the fetus first demonstrates responses to such stimuli. Defining pain as the response to something painful was the approach taken by Stuart Campbell when I debated him on BBC News 24.

Unfortunately, defining pain as the response to something painful is tautological and much too permissive. Even fruit fly larvae will bend and roll away when close to a naked flame, but it is unreasonable to assume that the fruit fly larvae rolls away because it hurts. The roll is much better understood as a mind blind protective reflex. Mind blind reflexes also occur in humans and are generally associated with activity in the spinal cord and lower parts of the brain (the brainstem). Getting beyond a reflex response requires some psychological content that is generally agreed to require the higher neural centres of the brain. And that pushes pain out to at least 24 weeks when those centres develop and connect to the skin. Even after 24 weeks, however, there is still good reason to assume that the fetus is not psychologically complex enough to experience pain, as the report notes:

‘The fact that the cortex can receive and process sensory inputs from 24 weeks is only the beginning of the story and does not necessarily mean that the fetus is aware of pain or knows that it is in pain. It is only after birth, when the development, organisation and reorganisation of the cortex occurs in relation to the action and reaction of the neonate and infant to a world of meaning and symbols, that the cortex can be assumed to have mature features. The cortex is an important step beyond the spinal cord and brainstem because it facilitates pain experience by enabling the higher functions of cognition, emotion and self-awareness that are realised in the postnatal environment.’

Sensory experience is not something that falls directly out of a stimulus and neural tissue but is something that is always embedded in thought and context. There is no such thing as the pure experience of a packet of sensation; a touch is never just a touch. A touch on the knee can be an intrusion, an expression of concern or an overture to something more erotic. In each case the precise physical contact can be identical but the experience and feeling is very different. Ascribing pain or any other sensation to the fetus means ripping that sensation away from any situation - because ‘situations’ do not exist for the fetus - and in so doing we rip at the sensation itself.

The 2010 report also draws very solid conclusions regarding the use of fetal analgesia. Instead of focusing on pain the report recommends focusing future investigations on the practicalities and risks of administering fetal analgesia, the uncertainties over long-term effects for therapeutic interventions and the evidence for benefits to the fetus. The report notes that there is currently very little evidence of fetal analgesia providing any benefit to the fetus and concludes that, ‘on the basis of “first do no harm”, prior to the procedures described in this report, analgesia is no longer considered necessary, from the perspective of fetal pain or awareness.’

Finally, the 2010 report was thoroughly peer reviewed before being finalised. The reviewers were selected for their expertise and included reviewers on both sides of the abortion debate. Notably, Dr Kate Guthrie, a prominent supporter of abortion, and Professor John Wyatt, a prominent opponent of abortion, both provided their comments on a late draft of the report.

Undoubtedly there remain some significant problems with the 2010 report. Although it points out that development continues after 24 weeks and also notes the psychological nature of pain experience, which cannot develop in utero, the report draws an obvious distinction between pre- and post-24 weeks. That distinction was particularly noticeable in the RCOG press release, which noted that ‘the fetus cannot feel pain before 24 weeks’, but also that ‘more research is needed into the short- and long-term effects of the use of fetal analgesia post-24 weeks’. The press release implied that pain occurs after 24 weeks and the report itself can be seen as sometimes supporting pain after 24 weeks and sometimes not.

The emphasis in the report on fetal sleep and sedation throughout pregnancy was perhaps an attempt to step around the ambiguity of what happens after 24 weeks. If the fetus is asleep and sedated throughout pregnancy then it doesn’t matter whether it can feel pain or not because we don’t feel anything when asleep. In my view it is not at all clear what ‘sleep’ really means for the developing fetus and I suspect that the notion of fetal sleep and sedation will come under increasing scrutiny over the next few years. Fetal sleep and sedation cannot entirely resolve the tension over consciousness, pain and awareness because sleep itself raises an argument over the nature of consciousness and awareness.

That there are some remaining tensions and ambiguities is not surprising. To provide a consensus on fetal pain would require consensus on the biology of pain, the psychological content or nature of pain and on the development of human consciousness both in and out of the womb. As one of my colleagues recently suggested, hell will likely freeze over before that happens. Consensus is, in any case, overrated. The point is not to provide a consensus statement that closes down debate but to provide a document that cogently summarises the key points and research to date. The 2010 report does that beautifully and is an important document for the arguments and debates that will follow.

Stuart WG Derbyshire is a senior lecturer in the School of Psychology, University of Birmingham. He was a member of the Working Party providing written contributions for the 2010 RCOG report and attending four meetings between July 2008 and July 2009. This article was first published on spiked.

(1) Fetal Awareness: Report of a Working Party, RCOG Press, London, 1997

(3) Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales: Report of a Working Party, RCOG Press, London, 2010

Australian attitudes to early and late abortion

A study of public opinion published in the Medical Journal of Australia has found a high level of support for access to early abortion, and little support for professional sanctions against doctors for providing terminations after 24 weeks’ gestation.

Abstract

The study set out to investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.

This was an anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008. The main outcome measures were attitudes to abortion, particularly after 24 weeks’ gestation.

The results found a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.

The authors concluded that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

The study

The authors note that abortion laws in Victoria were reformed in October 2008 following a review by the Victorian Law Reform Commission, and that abortion laws elswhere in Australia are currently under debate. Previous surveys of community attitudes to abortion have several limitations: it is unclear what proportion of those who support the right to access abortion believe that it should be restricted on the basis of factors such as gestational age and women’s reasons for seeking abortion.

The authors also note that Europeans tend to support women’s access to abortion; Americans are more likely to oppose it. ‘Late’ abortion is especially controversial, although less than 2% of abortions occur at 20 weeks or later. Few data support the belief that Australians strongly oppose women’s access to late abortion.

This study found that 87% per cent of respondents indicated that abortion should be lawful in at least some circumstances in the first trimester; 69% indicated this for the second trimester and 48% for the third. In a wide range of clinical and social circumstances, a majority of respondents indicated that doctors should not face professional sanctions for terminating a pregnancy after 24 weeks’ gestation. In no circumstance did a majority indicate that a doctor should be sanctioned for terminating a pregnancy after 24 weeks’ gestation. Of the subgroup of respondents who indicated that termination of pregnancy in the third trimester should be unlawful, a majority indicated that doctors should not be sanctioned for terminating a pregnancy after 24 weeks’ gestation in six of 16 circumstances. In the same subgroup, there was majority support for professional sanctions in five of these 16 circumstances.

There were no statistically significant differences between the responses, regarding attitudes to both lawfulness of abortion in each trimester and to sanctions in the various circumstances, of respondents who resided in Victoria and those who resided in any part of Australia, nor between men and women. Seventeen per cent of women indicated they had personally had a pregnancy termination, and these women were more likely to oppose sanctions than the female population generally. Respondents aged 45 years and older were more likely to oppose sanctions than those aged 18–44 years. Respondents who nominated a religious affiliation were slightly more likely to support sanctions than those who reported no religion.

Discussion of findings

The authors noted that their survey shows a high level of support for access to early abortion. There was little support for professional sanctions against doctors for providing terminations after 24 weeks’ gestation. When asked to consider specific, realistic situations in which late abortion might be considered, many respondents opposed sanctions against doctors, particularly when abortion is sought because of maternal or fetal complications rather than personal reasons.

The authors argue that public opinion research can have a major impact on government policy and, therefore, on access to quality medical care. To the authors’ knowledge, this is the first detailed survey of Australian attitudes to late abortion that includes attitudes in various clinical and social situations. Previous surveys in Australia have not usually specified the gestational age at which an abortion is performed.

Simple yes/no polls do not allow people to accurately express the subtlety of their views in the complex range of clinical and social situations in which access to abortion might be sought. For example, although 48% of respondents indicated that abortion in the third trimester of pregnancy should be unlawful, less than a quarter indicated that a doctor should face professional sanctions for performing termination after 24 weeks’ gestation when there is a risk to the physical or mental health of the woman or baby.

Respondents were more equivocal about sanctions in scenarios regarding late termination for reasons relating to the preferences or social circumstances of the woman. But less than 50% of respondents indicated that a doctor should face professional sanctions for performing a termination after 24 weeks’ gestation, even when there is no medical reason for the termination.

The authors argued that one possible explanation for the difference in responses to questions about lawfulness and sanctions is that respondents drew a distinction between legalising abortion and removing sanctions. Respondents with ambivalent attitudes to abortion may favour removal of sanctions but retention of a legal bar on abortion as an intermediate position between full legalisation and full prohibition. This could reflect the prevailing semi-legal status (which was in place until recently in Victoria, and is still in place in most other Australian jurisdictions), where abortion is illegal under at least some laws but professional sanctions are rarely, if ever, enforced.

Another possibility is that respondents may have an in-principle objection to abortion but are more prepared to accept it when they understand the reason, especially if there is a medical reason for abortion. Support for abortion was generally higher when respondents were given greater information about timing and reasons.

The authors speculate that this higher level of support could have been because respondents had a greater ability to identify with women seeking an abortion when contextual information was present, or because respondents thought that the contextual details were morally relevant factors — that is, that they provided moral reasons for allowing abortion. It is possible that, when no context is given, respondents tend to assume there are no significant moral reasons for abortion to proceed.

The authors argue that the sensitivity of Australians’ views on abortion to contextual details may have implications for other debates about ethics. The more permissive attitude elicited when context was provided in this study may, for example, carry over to debates about euthanasia, the use of medicine or technology for human enhancement, organ donation, and embryonic stem cell research. A simplistic division between ‘pro-choice’ and ‘anti-abortion’ does not accurately reflect the views of Australians: individuals have nuanced views that depend on the reasons for which women seek abortion. Nonetheless, opinion surveys — no matter how robust — should not dictate policy or law.

The authors conclude that policies and laws should be grounded on ethical arguments, and they have attempted to provide such arguments, adding to previous discussions of abortion and the law. This study has shown that Australians are supportive of both access to abortion, including late abortion in many circumstances, and liberal abortion law reform.

The full study is avalailable here:

Australian attitudes to early and late abortion. de Crespigny, L., Wilkinson, D., Douglas, T., Textor, M. and Savulescu, J. (2010), Medical Journal of Australia, Vol: 193(1) pp. 9-12

More detailed data from the survey are located here. 

‘Enhancing the lives of children: How far should we go?’

A conference at the Royal Society of Medicine raised some interesting and important questions about how today’s society should view the role of genetic, chemical and behavioural techniques in shaping children’s health and behaviour. Jennie Bristow reports.

This conference, held on 29 June, was distinctive in bringing together a number of different ‘forms’ of enhancement. Professor Julian Savulescu, Uehiro Professor of Practical Ethics at the University of Oxford, gave a skilfully-argued presentation on the theme of ‘The moral imperative to enhance human beings’.

He noted that as society has developed, it has become more demanding of people’s cognitive abilities, providing a compelling argument to enhance these abilities where possible. Explaining that a 20 percent of the US population cannot complete simple tasks that enable them to function in modern society – for example, reading bus timetables – he posed the question of whether such people should be considered ‘effectively disabled’, and ‘if we had could improve this through biology, why wouldn’t we?’ Professor Savulescu argued that using enhancement techniques was preferable to ‘pathologising normal human variation’, which he suggested may be the case in the expanding diagnoses of Attention Hyperactivity Disorder (ADHD). He argued that parents are best placed to decide issues to do with how their children are enhanced.

In a presentation on whether reproductive technologies can enhance the lives of future babies, Dr Alastair Sutcliffe, Senior Lecturer in General and Adolescent Paediatrics at the Institute of Child Health, London, focused on the limitations of Artificial Reproductive Technologies (ARTs): including that IVF has only a 20 per cent success rate, and a high proportion of multiple births, which are more likely to result in disability. His main argument was that whatever techniques, such as Preimplantation Genetic Diagnosis (PGD) exist that could enhance the babies born, the difficulties of conceiving with IVF provide a significant reason to reproduce naturally – and certainly not to delay one’s childbearing until later.

Professor Neil Marlow, of the Directorate of Women’s Health at University College London, discussed findings from the 2006 EPICure study on extremely premature infants. While there has been an increase in survival at very low gestations – such as 24 and 25 weeks – the outcomes for these extremely premature babies in terms of health, physical and learning disability remain very poor. He discussed the effect of extremely preterm birth upon families, who often face a lifetime of care, and concluded by arguing that those who work with extremely premature infants ‘have to think very carefully about what we’re doing’, as ‘the cost to society and families is huge’.

A presentation by Professor Stephen Scott, of the Institute of Psychiatry at King’s College London and Director of Research at the National Academy for Parenting Practitioners, was entitled ‘Enhancement of children’s lives through improving socialisation by parents: New Jerusalem or Big Brother?’ He claimed that there was some evidence that ‘good parenting’ techniques work, for example by encouraging desirable behaviour and setting firm limits, and presented a graph indicating young people’s outcomes at the age of 25 relative to how antisocial they had been at the age of seven.

Scott argued that parent training should be done by professionals, as untrained parent trainers can have a negative impact, and raised the ethical issue of to what extent birth parents should be forced to attend parenting classes: should it be like the French system promoting immunisation, where children who have not been immunised cannot go to school?

Mr Robert Wheeler, Consultant in Paediatric and Neonatal Surgery, Southampton University Hospitals Trust, discussed the use of surgery to enhance lives of children. He noted that surgery is routinely carried out on children to correct physical oddities, even if these are not dangerous – for example, the removal of breast-buds in adolescent boys – and argued that such techniques could have important benefits for the self-confidence of children and adolescents, and also their families. He also spoke about the difficulties involved in negotiating cultural practices, such as male circumcision (which is permitted in the UK, with consent from both parents) and female circumcision (which is prohibited).

Professor Eric Taylor, of the Institute of Psychiatry at King’s College London, gave an eloquent presentation on ‘Enhancing children’s cognition and behaviour by chemicals: what’s possible; what’s right?’ He noted the positive effect that treatment for conditions such as ADHD can have, but also addressed some of the issues involved in enhancing children who are not impaired. For example, if a particular drug encourages compliance, care has to be taken because we do not want a society that is too compliant. The use of cognitive enhancing drugs, as is widespread amongst students at Yale and Harvard universities, can potentially replicate and increase social inequalities, when it comes to those who cannot afford the drugs.

Professor Taylor also raised the issue of young people’s autonomy and sense of authenticity – expressed, for example, in the question amongst many families of children taking drugs for ADHD about whether they should take their medication at weekends.

Professor Jonathon Montgomery, Professor of Law at Southampton University and Chair of the Human Genetics Committee, discussed some of the complexities of regulating techniques intended to enhance lives of children. He discussed the argument that a child’s right to self-determination is damaged by enhancement techniques, noting that to some extent enhancement is what parenting is all about. Professor Montgomery argued that ‘whatever we do’ – whether regulation by law, or through prescription of drugs – is regulation in one form or another, and said that ‘we will end up doing something, but it is not clear how much good it will do’.

The final presentation was given by two members of the Youth Advisory Panel of the Royal College of Paediatrics and Child Health, London, giving a ‘young person’s perspective’ on enhancement. These young people were more wary of enhancement techniques than the speakers had been, raising issues to do with personal autonomy and identity. One drawback of a focus on enhancement through drugs were, they noted, ‘the impression upon youth that medicine can be a quick fix to problems’.

Taken all together, the presentations and the discussion that flowed from them provided a number of interesting insights and raised one key question. As scientific understanding of the human body and brain has increased, so more and more technologies are being developed to detect and modify disability, and to enhance characteristics such as cognitive function that are perceived as desirable. But to what extent can – and should – science and medicine be perceived as the key route for human improvement?

Much of the debate about ‘designer babies’ has been stuck in an argument about nature vs science, where the opposition to using technology for human enhancement is largely grounded in fears about ‘playing God’. When it comes to parents using techniques such as PGD or sex selection to ‘choose’ their future children, the debate tends to focus on the problems of individuals making the wrong choices, for the wrong reasons - and thereby insulting people with disabilities, or creating a society dominated by girls (or boys). But these preoccupations miss what seems to me to be the genuinely disturbing feature of the ‘enhancement’ discussion today.

Individuals making choices about their future children – whether through ‘natural’ means such as partner selection, ART, or abortion – have personal and generally reasonable reasons for doing so. Furthermore, what individuals decide in relation to their own families rarely makes a major impact upon society: if a few couples used ART for sex selection in the UK today, it would not result in a massive demographic change in the gender ratio.

Professor Stephen Wilkinson’s recent book, Choosing Tomorrow’s Children: The ethics of selective reproduction, does a superb job of engaging with the ethics of selective reproduction, and demolishing from an ethical standpoint many of the contemporary fears that parents making choices in this area are engaged in practices that are morally wrong or socially problematic.

Specifically, Wilkinson challenges the argument that individuals making choices about selective reproduction through ART are practising a form of eugenics, for which he adopts the working definition of ‘”the attempt to improve the human gene pool”’. Such an attempt, argues Wilkinson, is not wrong per se, but the means by which eugenic ends are pursued can be wrong: for example, with compulsory sterilisation programmes.

A key distinction is between individual decision-making and social policies. If individuals make decisions for health and welfare reasons, which relate to their own circumstances and to pursuing broader social ends, this cannot reasonably be problematised as eugenics.

However, eugenic means are not entirely absent from discussions about reproductive decision-making today. It has been argued, for example, that the official focus on preventing teenage pregnancy has eugenic overtones, in its desire to use birth control to stop the ‘wrong people’ having babies. Similarly, neo-Malthusian arguments that encourage people to have no more than two children in the interests of reducing global promote restrictions on reproductive choice as a means to achieving broader social ends. These arguments are a cause for concern amongst those committed to reproductive autonomy and choice.

There is also a tension inherent in the promotion of science as a means to human enhancement, when such enhancement is understood in such narrow terms as cognition or behaviour. An argument that recurred over the course of the RSM conference was that society has traditionally enhanced children’s cognitive development through education, so why should it balk at cognitive-enhancing drugs?

For those who accept the improvements that science and health have made to human wellbeing, and are open to the exciting possibilities of future developments, it is difficult to have a principled objection to cognitive-enhancing drugs. Yet there is surely an important difference between enhancing children’s brains through education, and through drugs. Education is a social project, facilitating the generational transmission of knowledge and values from older people to younger people, involving a range of different influences and personalities. Cognitive enhancement through drugs does not contain this broad human aspect – for all the benefits that such drugs might bring, in their own terms they treat interact with children, not as young people, but as purely biological beings.

The somewhat one-sided focus on technical methods for enhancing children is not restricted to discussions about chemicals, or ARTs. Stephen Scott’s presentation revealed the extent to which the narrow focus on particular parenting techniques, which are measured in terms of behavioural outcomes and tend to be promoted to particular groups of parents, echo the determinism of sociobiology and intrude on people’s intimate practices and personal choices in matters of child-rearing. The idea that parenting classes could even be discussed in the same way as childhood immunisation reflects the narrowness of contemporary ‘parenting science’.

The focus on enhancing individual children also sits uncomfortably with a socially-oriented outlook. It is easy to understand why parents might choose almost any attempt to improve their children’s life chances – to a parent, the individual child is the focus and the priority. But to policymakers and medical institutions, there is no one special child: the question on the agenda has historically been about improving the life chances of children as a group. To focus on individual solutions to what have historically been understood as social problems – differences in educational achievement, for example, or anti-social behaviour – arguably pushes the search for social solutions further down the agenda.

In raising all these questions, the RSM conference made a valuable contribution to the debate about enhancing children. A further discussion of these issues will take place in October 2010, in a session sponsored by BPAS at the London Battle of Ideas festival, where Professor Stephen Wilkinson will discuss the ethics of selective reproduction. For further information, contact .

France: Sexuality and obesity, a gender perspective

The study set out to analyse the association between body mass index (BMI) and sexual activity, sexual satisfaction, unintended pregnancies, and abortions in obese people and to discuss the implications for public health practices, taking into account the respondents’ and their partners’ BMI. From the British Medical Journal. 

This was a random probability survey of sexual behaviours: a national population based survey of 12 364 men and women aged 18-69 living in France in 2006. Participants were a random selection of 5535 women and 4635 men, of whom 3651 women and 2725 men were normal weight (BMI 18.5-<25), 1010 women and 1488 men were overweight (BMI 25-<30), and 411 women and 350 men were obese (BMI >30).

The results found that obese women were less likely than normal weight women to report having a sexual partner in the past 12 months (odds ratio 0.71, 95% confidence interval 0.51 to 0.97). Obese men were less likely than normal weight men to report more than one sexual partner in the same period (0.31, 0.17 to 0.57, P<0.001) and more likely to report erectile dysfunction (2.58, 1.09 to 6.11, P<0.05). Sexual dysfunction was not associated with BMI among women. Obese women aged under 30 were less likely to seek healthcare services for contraception (0.37, 0.18 to 0.76) or to use oral contraceptives (0.34, 0.15 to 0.78). They were also more likely to report an unintended pregnancy (4.26, 2.21 to 8.23).

The authors concluded that there is a link between BMI and sexual behaviour and adverse sexual health outcomes, with obese women less likely to access contraceptive healthcare services and having more unplanned pregnancies. Prevention of unintended pregnancies among these women is a major reproductive health challenge. Healthcare professionals need to be aware of sensitivities related to weight and gender in the provision of sexual health services

INSERM (Institut National de la Santé et de la Recherche Medicale), CESP Centre for Research in Epidemiology and Population Health, U1018, Gender, Sexual and Reproductive Health Team, F-94276, Kremlin Bicetre, France.

Sexuality and obesity, a gender perspective: results from French national random probability survey of sexual behaviours. Bajos N, Wellings K, Laborde C, Moreau C; CSF Group. British Medical Journal. 2010 Jun 15;340:c2573. doi: 10.1136/bmj.c2573.

Commentary: Women shouldn’t apologise for having abortions

Writing in the New Statesman, Laurie Penny argues that it’s time to build an ideological case for abortion on demand.

Penny writes:

When will women be allowed to stop apologising for having abortions? This week, news came in that 34 per cent of women who terminated pregnancies in 2009 had already had one termination—including “dozens” of teenage girls on their third abortion. Seven dozen, in fact, totalling a huge 0.04 per cent of all terminations.

Conservative commentators wasted no time lathering themselves into a foam of moral approbation, declaring the statistics an “appalling” demonstration of “the failure of . . . values-free sex education” and raising concerns that “abortion is being used as a form of contraception”.

“These statistics are tragic,” said one American source. Are they really? With teenage abortions rising at roughly the same rate as teenage births are falling, the new statistics could be viewed as cause to celebrate that fewer young women are bringing unwanted children into the world. For the moral minority, whose ideal solution to teenage pregnancy seems to be the confinement of all girl-children in windowless cells until their wedding day, acknowledging that abortion can have positive ramifications is a stumbling block—but the 76 per cent of Britons who are pro-choice have been slow to argue that not every abortion is an occasion for abject contrition.

Even the feminist left has a tendency to triangulate on abortion. At a pro-choice rally in October 2008, I was disappointed to hear the current Labour leadership candidate Diane Abbott declare that “every abortion is a tragedy”. Abbott, who tabled amendments to the 2008 Human Fertilisation and Embryology Bill to extend legal abortion to women in Northern Ireland, is uncomplicatedly a pro-choice hero—yet even she seemed to feel a need to justify women’s right to control their own bodies on the basis of remorse.

The notion that repeat abortions in particular are “tragic” cuts to the heart of liberal-conservative moral posturing on the issue. One abortion might just be permissible, but only as long as the woman in question feels sad about it for the rest of her life and never does it again. An ideological carapace of secrecy and shame still encases public discussion of abortion, and the right-wing press is careful to paint women who have multiple terminations as heartless, amoral strumpets.

According to the finger-jabbing conservative commentariat, abortion has become a sexy “lifestyle” option, with teenage girls popping in for quick terminations between geography and double maths, reading emails and filing their nails while hunky doctors carry out the procedure with sparkly pink surgical implements. In the real world, abortion is a painful inconvenience. Smilarly, appendectomy, the most common occasion for minor surgery, is not considered a “tragedy”, but nor is it the social event of the season. There are many reasons why a woman might find herself in need of a second or third termination, from a history of abuse, to bad luck, to simple carelessness. None of these should be reasons to withhold abortion as a health-care service.

“I’ve had two abortions, at different times in my life and for different reasons,” said Anna, 34. “If one believes in the right to choose, then as far as I’m concerned, that right doesn’t disappear after you’ve chosen once. It’s not a fun procedure, and ideally no one would have to have it, but to make moral judgements about someone who’s done it more than once is to make a judgement on the existence of the procedure at all.”

The NHS is not a moral arbiter, and doctors never refuse to treat addicts, alcoholics, or gang members who acquire wounds in senseless combat. Only women with unwanted pregnancies are obliged to justify their health-care decisions before receiving treatment.

The legal status of abortion in Britain is so encrusted with misogynist moral debris that, four decades after legalisation, women still have to obtain permission from not one, but two doctors, a legal requirement that delays the process, wastes NHS time and prolongs the unnecessary fear and anxiety associated with seeking abortion in Britain today.

“The worst part of the whole ordeal was obtaining the abortion—going from doctor to doctor, getting two signatures, worrying I wouldn’t be able to get an appointment,” says Dawn, 23, who had a termination last year. “I felt as though my body didn’t belong to me because I hadn’t been able to control my fertility despite my best efforts—I was on the implant. The thought of having to have a child I didn’t want was terrifying.”

Like many women, Dawn has never regretted her abortion, saying that “after the procedure I felt that I had control of my life again. I never felt that I should have done anything differently. All I felt was relief, not tragedy.”

Many women do feel sadness or grief after having an abortion, and those feelings deserve respect. However, to state that “every abortion is a tragedy” undermines the plethora of powerful arguments for choice. Reproductive health care should not be a source of shame. With British women’s right to make decisions about their own bodies under threat from pro-life pundits within Westminster, now is the time for the pro-choice lobby to cease pandering to conservative propaganda and start building an ideological case for abortion on demand.

Women shouldn’t apologise for having abortions, by Laurie Penny. New Statesman, 18 June 2010

Why do people get pregnant (when they don’t want to be)?

The 2010 BPAS annual lecture was given by Kristin Luker, the foremost American sociologist researching contraceptive use and risk taking around unplanned pregnancy in the USA.

The second in BPAS’s programme of annual lectures was given by Kristin Luker, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology at the University of California, on 21 June at the British Library in London. 

Ann Furedi, chief executive of BPAS, and Ian Hammond, BPAS chair of trustees, introduced the lecture, thanking Professor Luker, and also the British Library for hosting the event. Furedi explained that in addition to BPAS’ role as leading provider of abortion services in Britain, it has a public education remit to educate politicians and policymakers and the public about the causes and consequences of unwanted pregnancy.

Professor Luker is the foremost American sociologist researching contraceptive use and risk taking around unplanned pregnancy and sex education policies in the USA. She has advised the White House on issues in teenage pregnancy, and published five ground-breaking books, including Taking Chances: Abortion and the decision not to contracept (1975), Dubious Conceptions: The politics of teenage pregnancy (1996), and When Sex Goes To School (2006). Her 1985 book Abortion and the Politics of Motherhood was nominated for a Pulitzer Prize.

Professor Luker began by speaking of her honour at being able to share her research and experience with an audience of activists and abortion care practitioners. ‘Somebody once said to me many years ago that activists worry about waves and scholars worry about tides,’ she said. ‘I’ve had the luxury, for 40 years, of worrying about the tides but it would be all irrelevant if those of you here were not worrying about waves, and what’s happening on a day to day basis.’

The question that Luker set out to address was, ‘why do people get pregnant when they don’t want to be?’ This, she noted, seems like a straightforward question – but when opened up, it becomes enormously complex. She first became interested in the question while volunteering at Planned Parenthood in 1969, at a time when California had liberalised its abortion law before the United States had done so as a whole. Over the course of the summer, she saw three different women coming in who had recently had abortions and were returning because they thought they might be pregnant again.

‘I didn’t know much about abortion, but I thought I knew that if you’d had an abortion reasonably recently normal people would try to avoid another one,’ she said. ‘So I saw these three people and, as I say to my students, one person is a flake, two people are a flake and a friend, and three people are a social trend. So that got me interested in this notion of unplanned or unwanted pregnancy – and pregnancies that end up in abortion.’

The first points that Luker stressed were that abortion is not just about women; and that it’s not just about teenagers. ‘If you’ve read much of the American social science literature, you would think women had sex all alone, got pregnant all alone, had abortions all alone and raised children all alone,’ she noted; and her research addresses this balance by also looking at decision-making within couples. And while America, like Britain, is ‘obsessed’ with teenage pregnancy, in fact ‘American adults are remarkable in our capacity to get each other pregnant when we don’t want to be, and to give each other sexually transmitted diseases’.

The key question is, for all adults, ‘why should there be so much abortion in countries where contraception is legal, it’s accessible, and it’s subsidised?’ After four decades of research, Luker has concluded that ‘there are three levels of forces impinging on people: at the level of the individual, at the level of the couple, and at the level of society.’ Recognising this situation raises ‘some very difficult and awkward questions’ to do with unplanned and unwanted pregnancy: ‘unplanned by whom? And more subtly, and more deeply, unwanted by whom?’

Contraception, decision-making and abortion

When it comes to decision-making about pregnancy and contraception, explained Luker, ‘there’s an individual person engaged in a decision-making process that ends in a pregnancy that ends in an abortion. There’s a couple, for however briefly that couple exists, and they’re engaged in negotiating and assigning meanings and making decisions. And then there are some larger social forces’. Understanding the process involves examining all three of these dynamics, and how the relate to each other.

Luker explained that ‘individuals define for themselves what it means to contracept – or not. Couples, and the dynamic between the couples, define what using contraception means – or not. And most importantly, the larger-changing political, social and cultural forces that define and redefine the meaning of sex, pregnancy, marriage and birth’. This latter process is what has come to interest her particularly in recent years, as ‘the world has changed enormously’ since she first began researching these issues.

Luker noted that how individuals think about contraception, birth, pregnancy and abortion is ‘actually an enormously complicated risk analysis’. Individuals calculate the costs of contraception, the benefits of getting pregnant, the probabilities of pregnancy, and the probabilities of reversing the ‘decision’ – as she said, ‘I put “decision” in quotes because it’s much too formal a word for what I think really happens’. She explained:

‘The way this process works out is somebody says, “you know, it’s really a bother to ask him to get out of bed on a cold night and put on a condom. I probably won’t get pregnant. If I got pregnant he might marry me. And worst coming to worst, I can always get an abortion”.’ This, according to Luker, is a rational way of thinking about things – even if events do not turn out this way in reality.

Luker discussed the research she conducted for her 1975 book Taking Chances. Her research was with a group of people who had successfully shown that they knew how to use contraception in the past, yet had not used it to prevent the pregnancy they were currently experiencing. ‘When I talked to them, it turned out that it was because contraception brings social, physical and emotional costs,’ she explained. ‘The social cost is, you have to acknowledge that you’re going to be sexually active. A surprising number of people in my very first study, and a surprising number of young people I talk to today, go off the pill when they break up with a boyfriend, because they’re not “looking to have sex” and they don’t want to look like a woman who’s “looking to have sex”. So it was a common pattern many years ago and it’s still common.’

Luker mentioned other reasons that women give for not taking the pill, for example weight gain. ‘Now to you and me, gaining weight weighed against an unwanted pregnancy that ends in an abortion isn’t a very big deal, but given anything else that’s going on – you don’t know if you’re going to get pregnant, you don’t know what pregnancy means to you, you don’t know whether or not you’ll go ahead and end the pregnancy – all of those things affect how people think about the cost of contraception,’ she said. Similarly, some women talked about pregnancy bringing a ‘pay-off’. For example, one woman talked about how her father would hit her, but that ‘nothing, not even him, can ever take away the experience of being pregnant’; while others talked about being reassured that they could get pregnant.

Trying to calculate the odds of getting pregnant, explained Luker, is ‘a statistician’s nightmare, and it’s not surprising that individual people have a hard time with it’. A common statistic used is that healthy women in a regular sexual relationship have an 80 per cent chance of pregnancy over the course of a year. ‘But it only takes a moment’s reflection to realise that you don’t get 80 per cent pregnant – it’s zero or one. So calculating your aggregate risk is very difficult, and many people will just sort of use a condom during what they thought was the unsafe time of the month, or they’d use a diaphragm or maybe some foam, and when nothing happened they’d stop using it a little bit more, and more, and more. And finally the last step in this process is that people said to themselves, worst coming to worst, I can always get an abortion.’

In this way, the existence of legal abortion has transformed the situation of 40 years ago, when ‘abortion was such a taboo topic that people didn’t actually use the word’ and the risk attached to unwanted pregnancy were much higher. As such, ‘the existence of legal abortion lowers the entrance cost into this decision-making process’.

Luker went on to talk about risk-taking at the level of the couple. In almost all cases, pregnancies occur within a couple, no matter how brief the existence of that relationship is’. Both individuals bring individual assessments to the idea of risk taking, but they also bring ‘couple assessments’, where men and women try to figure out what contraceptive risk-taking and a possible pregnancy means in a relationship. ‘What does this relationship mean to my partner? Where is this relationship going? What does it mean that he or she is not using contraception? What will a baby mean for our relationship?’

The different meanings that individuals within couples whom she interviewed would bring to contraceptive risk-taking are, explained Luker, ‘very poignant. Because the man was saying, “I know she’s not using contraception, but it’s her body”. And the woman was saying, “I know we’re not using contraception, but it’s his baby”’.

The decision-making process, both on the level of the individual and the couple, is affected by broader factors: gender dynamics, and, most importantly in Luker’s view, ‘the changing meaning of sex and pregnancy’.

The changing status of marital motherhood

Reflecting on the social changes since she began her research, Luker argued that ‘marriage is increasingly becoming a luxury good’ - something that ‘the well-to-do engage in’. She suggested that the USA was emulating a pattern previously seen in less affluent societies, where couples in all kinds of relationships would have babies, but only the ‘top tier’ would marry. People ‘aspired to marriage as their ideal, but they didn’t hold off their childbearing until they had achieved that’.

To the extent that the dream of marriage is ‘iconic’ in most societies, Luker argued that it is ‘quite worrisome’ that marriage is declining in the United States. As she noted, ‘the evidence suggests that it’s not my generation of women here who didn’t want to get married because we didn’t need a piece of paper to prove to the state that we were with a partner, but increasingly includes people who would marry if they could but they can’t. And that’s an incredibly complex process.’

Luker devoted the remainder of her lecture to unravelling what the decline in marriage means for abortion and the politics of motherhood. This raises a series of difficult and challenging questions.

Luker’s 1985 book Abortion and the Politics of Motherhood argued that abortion divided women over the issue of motherhood: between ‘those women who were socially situated to be on equal terms with men, and women who couldn’t’. What has become increasingly apparent since the book’s publication, she argued, is ‘the class dimension of that divide’. She presented a graph showing the rapid increase in the percentage of female first-year students in professional programmes such as medicine, law, MBA, and dentistry since 1973. Acknowledging that this reflected cultural change too, she said ‘I believe it’s abortion that finally commits women to invest human capital in themselves and, more importantly, changes the expectations of others that that’s what she would do’.

Addressing the question of why this big change was not seen in 1965, when the Pill was widely used in the USA, Luker stated that the gap between the Pill and abortion is, in fact, a ‘chasm’. ‘When I was in graduate school, an advisor actually told me that he could not give me a fellowship because I might get married and have children,’ she recounted. ‘That would be so unthinkable after 1973: not only because there’s a women’s movement, but because there’s an exit option’. Consequently, a group of women went on to become professionals – but that ‘left behind’ those women who were not so situated.

Luker explained that the argument of Abortion and the Politics of Motherhood was that ‘for many of those women, being a mother was the best job they could aspire to. It had moral meaning, it had social cachet, it was something that was respectable, and that what abortion did was in some ways undercut the social and moral meaning of motherhood.’ However, she reflected, this analysis did not take account of the signficance of marital motherhood.

Presenting graphs showing the proportion of people married or cohabiting in the USA, broken down by education level and by poverty, Luker noted that ‘marriage increases at each level of education, cohabitation decreases’. Similarly, the more affluent people are, the more likely they are to be married. Thus, ‘marriage is becoming less common – but not childbearing’. In 2008, 40.6 per cent of all births in the United States were to unmarried women. This is a ‘racialised phenomenon’. As she argued, ‘marriage is becoming the purview of the reasonably affluent upper middle class – mostly white’. A similar trend of greater proportions of babies being born out of wedlock, noted Luker, is taking place in most Western democracies.

‘Ticklish questions’

These trends, argued Luker, raise a number of ‘ticklish questions’: the first of which is, what does it mean for pregnancies to be unwanted? ‘It seems to me that one of the things that we have not been as forthright in confronting as perhaps we should have been are the taken-for-granted assumptions that babies born to young people, to poor people, and to non-white people, are in some ways problematic babies a priori,’ Luker argued. As she has argued in her books, ‘the rhetoric of teenage pregnancy universalises what is in fact a classed and racialised situation. That is, most women do not say, “Well, I could be a teenage mother or I could go to Harvard Medical School – I think I’ll be a teenage mother!”’

Given the process by which women are ‘sifted apart’ by class and race, Luker argued, ‘it’s extremely important – and I say this as someone who became a feminist the very first time she heard the word – not to universalise women’s experience, to call into our awareness that what it means to undergo sex, pregnancy or abortion is very much a product of your background and not just your gender.’

Another question relates to the changing social circumstances under which abortions take place. Luker argued that the women who were having abortions in the early 1970s were women who didn’t want to be pregnant. ‘If you talked to people in those days, they said it was a relief. They said that it gave them something they would not otherwise have,’ she explained. Today, by contrast, ‘we are increasingly seeing a population of women who would rather be pregnant, but cannot continue the pregnancies for reasons not having to do with their own volition’.

This again raises the question of what it means for a pregnancy to be ‘unwanted’. Luker argued that for an increasing number of women, it’s a ‘lottery ticket’: ‘if you win, you win big; if you lose, you don’t lose that much. So unintended pregnancy may well be a way of exploring for yourself whether or not motherhood, with or without a partner, is a viable option’. This trend, she argued, is extremely worrisome – especially for those working in the field of reproductive choice. As she argued:

‘I’m old enough to remember illegal abortion, and the idea then that you could get a safe, clean, legal abortion was amazing. But if abortion becomes the mechanism by which women’s dreams become smashed, these are not women who are going to support choice. These are people who say, “I really don’t believe in abortion but my case is different”. And I worry that that group is growing’.

Finally, Luker raised the concern that, as shown in US public opinion polls, ‘abortion is one of the few issues where younger women are more conservative than older women’ – in contrast to where they stand on most other social issues. Because young people lack any sense of a world in which safe, legal abortion was not available, she argued, they are more likely to adopt the view that ‘I guess abortion is ok for some cases, really hard cases, but I’m not like all those other people who get casual abortions’.

In conclusion, Luker said:

‘So I think the future is worrisome. It’s invigorating, it’s challenging, luckily there are people in this room like you to do something about it, but I think there are some storm clouds on the horizon that we need to think about very deeply, and need to build into our tidal thinking at the same time that you are thinking about the waves.’

Discussion

Professor Luker’s lecture was followed by a lively discussion amongst attendees of the lecture. Ann Furedi thanked her for challenging much of assumptions and assumed standards that exist in the UK, at the policy level and in relation to service delivery – for example, the assumption that teenage pregnancy is the result of insufficient or inadequate sex education, or to do with access to, or the effectiveness of, contraception. If the issues are reducible to this, the implication is that there can be ‘a quick fix’ – whereas Luker’s research suggests the ‘rich tapestry’ of this area.

David Paintin FRCOG, Emeritus Reader in Obstetrics and Gynaecology at Imperial College School of Medicine at St Mary’s, London, and one of the doctors who helped to bring the 1967 Abortion Act into being, reflected on the impact of Luker’s book Taking Chances on the discussion of abortion in the UK, at the time of its publication in the mid-1970s. At this time, noted Paintin, doctors had begun to interpret the 1967 Abortion Act liberally, and it was becoming clear that women who wanted an abortion would be permitted to have one. Consequently, he said, there was a big demand for lectures to students and medics about abortion, and why unwanted pregnancies happened. The approach taken by Taking Chances, said Paintin, provided a way of understanding and explaining this issue that he continues to rely on today.

Referring to a study that she had been involved in conducting for the Department of Health about Early Medical Abortion, Dr Ellie Lee of the University of Kent asked about the extent to which changes in methods of abortion impact upon attitudes to risk-taking. She discussed how increased access to, and acceptability of, abortion through EMA did seem to indicated that women were more likely to have abortions – but that this was very difficult to talk about in policy circles.

Lisa Hallgarten, director of Education for Choice, asked Professor Luker how sociologists deal with the fact that ‘it’s all about story telling’, noting that when talking about abortion, young people develop a story after the event which helps them affirm their decision. Lesley Hoggart of the University of Greenwich referred to a research project she had recently conducted with teenagers who had had an abortion, and discussed how moralistic many of them seemed nonetheless. While they told stories, she said, they weren’t seeking to affirm their own decision – they were going against their own moral framework, and feeling bad. She stressed the importance of understanding the context in which teenagers make their decisions. 

Other questions related to young people’s perceived reluctance to use contraception because of an ‘anti-science’ perspective, which made them worry about putting chemicals into their bodies, what ideas might be behind notions of a ‘post-abortion syndrome’, and what the social causes of the drift away from marriage might be.

Professor Luker summed up her argument as: ‘abortion freed a certain class of women from marriage and motherhood on any other than their own terms, but it consigned another group of women to motherhood on less advantageous terms’. She reiterated the importance of understanding the context in which individuals made their decisions about motherhood. ‘If nothing exciting is happening in your life, pregnancy at least holds the promise that things could be different,’ she said. ‘And let’s face it, babies are wonderful, babies are compelling.’ While individuals do make up narratives, she said, ‘if you hear the same piece of the story many times it shows there is something reliable and socially relevant there’.

In conclusion, Ann Furedi picked up on an observation from one audience member that some of the discussion had sounded more familiar to conservative circles than those generally associated with the liberal left. ‘It’s interesting how much we all have to take a step back from preconceived ideas that we have associated with the pro-choice movement and look at what likes behind them,’ said Furedi. For example, ‘it’s very easy for us to think about unplanned sex in terms of risk but many young people think about it in terms of opportunity’. Attempting to bridge the gap between the way that individuals think about contraception and pregnancy, and the way that policymakers, service providers and some academics think about it, is an important challenge.

Report by Jennie Bristow.

UK: Important new review on fetal awareness published

There is no new evidence to show fetuses feel pain in the womb before 24 weeks, a report by the Royal College of Obstetricians and Gynaecologists has stated.

The RCOG has released two Working Party reports, Fetal Awareness and Termination of Pregnancy for Fetal Abnormality. Both documents were commissioned by the Department of Health, following recommendations by the House of Commons Science and Technology Committee (STC) in 2008.

The issue of whether a fetus of 24 weeks or below can feel pain had been raised in the 2008 Parliamentary debate over whether the current time limit for abortion should be reduced, BBC News Online reports. An up-to-date analysis of evidence was recommended by the the STC’s report Scientific Developments Relating to the Abortion Act 1967.

The main findings from each of the RCOG’s new documents are:

Fetal Awareness

-- The fetus cannot feel pain before 24 weeks because the connections in the fetal brain are not fully formed

-- Evidence examined by the Working Party showed that the fetus, while in the chemical environment of the womb, is in a state of induced sleep and is unconscious

-- The Working Party concluded that because the 24 week-old fetus has no awareness nor can it feel pain, the use of analgesia is of no benefit

-- More research is needed into the short and long-term effects of the use of fetal analgesia post-24 weeks.

Termination of Pregnancy for Fetal Abnormality

-- The Working Party concluded that it is unrealistic to produce a definitive list of conditions that constitute ‘serious’ handicap since accurate diagnostic techniques are as yet unavailable. Likewise, the consequences of abnormality are difficult to predict

-- The Working Party recommends that the NHS Fetal Anomaly Screening Programme is centrally linked so that the outcome of pregnancies with specific congenital abnormalities are monitored over time.

-- Appropriate information and support should be offered to all women undergoing antenatal screening

-- In the case of a possible termination of pregnancy, all staff caring for the mother must adopt a non-directive, non-judgemental and supportive approach.

The RCOG notes that the two reports are meant to be read together as both subject matters are closely related.  The first updates the previous report published in 1997, while the latter replaces the 1996 report.

Professor Allan Templeton, chair of the Fetal Awareness Working Party, said:

‘These two reports represent an extensive review of the scientific and clinical literature, and I am grateful to the many people who contributed and in particular to the members of the two working parties. I believe we now have robust and updated guidance for healthcare professionals.’

Ann Furedi, chief executive of BPAS, said that, taken together, the two reports would provide a clear basis for difficult decisions.

‘Women and doctors need to be able to make informed decisions based on what science says, not what advocates, whether pro-choice or anti-choice, wish it said.’

But those campaigning for further limits on abortion say these reports do not reflect the full debate on the issue.

Josephine Quintavalle of the campaign group Comment on Reproductive Ethics said:

‘I think both reports tell us more about the RCOG’s willing acceptance of late abortion than the reality of the scientific and ethical issues at stake.’

A Downing Street spokeswoman said:

‘The Prime Minister’s view is that he will be led by the science.’ She added: ‘At the moment there are no plans to change the policy.’

In the last vote on abortion in Parliament in 2008, MPs rejected a proposal to reduce the time limit for abortion from 24 weeks.

Read on:

‘No foetal pain before 24 weeks’. BBC News Online, 24 June 2010

RCOG release: RCOG updates its guidance. Royal College of Obstetricians and Gynaecologists, 25 June 2010.

Download the documents (.pdf):

Fetal Awareness - Review of Research and Recommendations for Practice

Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales

Also read:

UK abortion law section, Abortion Review

AR update, 21 June 2010

Keeping abortion decisions in context; teenagers and ‘repeat abortions’, government guidelines challenged in Northern Ireland; should women’s healthcare needs take priority over doctors’ beliefs?; and more ...

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This news digest is sent by email to those who have signed up to the Abortion Review Online mailing list. To join the mailing list for free, see here.

A quarterly news digest is provided in the print edition of Abortion Review. You can download the print edition for free here.

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- 1. KEEPING ABORTION DECISIONS IN CONTEXT

By Ann Furedi, chief executive of BPAS.

‘The revelation in the UK’s Sunday Times newspaper on 6 June 2010 that some assisted conceptions end in abortion was bound to cause consternation.

‘Increasingly, abortion has become accepted as a necessary back-up to contraception, essential to help women avoid unplanned, unintended pregnancies. But the abortion of carefully planned, deliberately conceived pregnancies does not fit into this framework of understanding.

‘When the Sunday Times contacted me for comment it was to discuss whether these abortions were a consequence of unscrupulous infertility doctors “rushing” women into ill-considered treatment; a lack of counselling offered to women seeking treatment; or a sign of a “throwaway” consumerist society where pregnancy might seen as nice one day and nasty the next.

‘But the explanation is obviously none of the above. The truth is that women who have help to become pregnant are still exposed to all the difficult stuff of life that blows ordinarily fertile women off their planned reproductive course...’

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Also read:

- 2. UK: ABOUT 80 IVF PREGNANCIES PER YEAR END IN ABORTION

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- 3. SHOULD WOMEN’S HEALTHCARE NEEDS TAKE PRIORIY OVER DOCTORS’ BELIEFS?

Jennie Bristow, editor of Abortion Review, comments on an important new report on conscience and refusal clauses.

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- 4. TEENAGERS AND ‘REPEAT ABORTIONS’: CONTRACEPTION IS NOT A MAGIC BULLET

Lisa Hallgarten, director of Education For Choice, comments on media claims that that 89 girls aged 17 or under who terminated a pregnancy last year had had at least two abortions previously.

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Also read:

- 5. UK: CONTROVERSY OVER TEENAGE ‘REPEAT ABORTIONS’

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- 6. NORTHERN IRELAND: ANTI-ABORTION CAMPAIGNERS CHALLENGE GOVERNMENT GUIDELINES

The Society for the Protection of Unborn Children (SPUC) has won permission to seek a judicial review of the controversial guidance.

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- 7. NORTHERN IRELAND: ABORTION LAW SHOULD CHANGE, GYNAECOLOGISTS SUGGEST

A survey claims that the majority of gynaecologists in Northern Ireland ‘do not support the current abortion law as it stands’.

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- 8. UK: REACTION TO TV ABORTION ADVERT

The first television advert for abortion, broadcast by Marie Stopes International, has generated positive and negative responses. 

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- 9. UK: CHRISTMAS ADVERT REVEALED

Protestant Churches are joining forces in an advertising campaign that shows a scan of ‘baby Jesus in the Virgin Mary’s womb’, complete with halo.

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- 10. USA: PALIN CALLS FOR CONSERVATIVE, ANTIBORTION FEMINISM

Sarah Palin, the former governor for Alaska, has provoked a barrange of commentary with her claims that women who oppose abortion rights are responsible for an ‘emerging, conservative, feminist identity’ and have the power to shape politics and elections around the issue.

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EVENT

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- 11. PREGNANCY AND PREGNANCY PLANNING IN THE NEW PARENTING CULTURE

This two day seminar on 22-23 June 2010, organised by Parenting Culture Studies and the Kent Centre for Law Gender and Sexuality at the University of Kent, UK, and supported by BPAS and the Economic and Social Research Council, will discuss the relationship between reproductive autonomy and a culture of ‘intensive parenting’. 

Speakers include:

-- KRISTIN LUKER, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology, University of California: ‘Abortion and the politics of motherhood revisited’

-- RACHEL JONES, Senior Research Associate, Guttmacher Institute, New York: ‘Abortion decision making in a culture of “intensive motherhood”’

-- DANIELLE BASSETT, Charlotte Ellertson Social Science Postdoctoral Fellow, Ibis Reproductive Health, Cambridge, MA: ‘Pregnancy after abortion: women’s experiences of a stigmatised reproductive career’

For details, see here.

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ABORTION REVIEW UPDATES

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For news updates from the UK, see here.

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For news updates from around the world, see here.

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For updates from the medical press, see here.

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Teenagers and ‘repeat abortions’: contraception is not a magic bullet

Commentary by Lisa Hallgarten, director of Education For Choice.

When the national abortion statistics came out in May, I wondered what negative spin we thought the press might put on them. From my point of view a reduction in rates across all ages, and the ongoing increases in the proportion of abortions happening earlier in pregnancy, was something to sing about. Unless we are all having less sex – for which I’ve seen no evidence – it indicates that more people are using contraception effectively and consistently. So what’s not to like?

The sexual health organisations put out their upbeat press releases and went back to the important business of trying to help women of all ages prevent unwanted pregnancy. It must have come as a relief to the nay-sayers that this silver lining had a cloud: and in this instance the cloud was said to be repeat abortion. 

Evidence that a small number of young women are having more than one abortion has become the headline news, and some journalists have been busy asserting the cause of this phenomenon: overly liberal ‘values-free’ sex education which doesn’t teach that some things (sex) are just wrong; sex education which does not tell us all ‘just say no’; a lack of seriousness about abortion which is leading women to ‘use abortion as contraception’; and a refusal to talk to young men about their responsibility for all this. Where do I start...?

Those journalists who are not anti-sex as such are concerned that we are just not getting the contraceptive message through to our young women and, of course, their concerns are mirrored by thousands of professionals working in sexual health, education, and health promotion. But are our contraceptive services really failing? The overall reduction in abortion rates suggest that they aren’t though there are doubtless improvements that could be made in the provision of contraception.

Education For Choice carried out a review of practice aimed at reducing repeat teenage conceptions and found lots of scope for improvement including increasing the range of contraceptive methods available in a greater number of settings; increasing awareness of using the IUD as emergency contraception; providing training so that more health professionals could provide a greater number of contraceptive methods; improving contraceptive counselling to optimise the chances of finding a suitable method for each individual woman; better education about contraception; and better provision of contraceptive counselling and contraceptive methods within maternity and abortion services.

What the report also found was that simply providing contraception is not a magic bullet. Many other factors influence the motivation and ability of young people to use contraception consistently and effectively. Some women in violent or coercive relationships are not supported to use contraception or may be physically prevented from doing so. Some women are ambivalent about pregnancy or fatalistic about their lives in general and may be unable to predict outcomes or plan effectively. Others may have personal or cultural resistance to some contraceptive methods and others – and this came out very clearly in research conducted by Lesley Hoggart on repeat abortion in London – have little understanding of their fertility and may falsely believe themselves to be infertile following previous abortion and/or having had unprotected sex without consequence several times. 

Young women in the care system may become intentionally pregnant in the hope that pregnancy will provide them with respect, independence, purpose and unconditional love only to realise once pregnant that they are likely to lose their child to the care system because of lifestyle factors that would put their child at risk. So many of these aspects of young people’s lives are beyond the remit of contraceptive services, and while some could be addressed within really good quality sex and relationships education there are no quick fixes.

It is important to approach the repeat abortion statistics with care. A statistic rarely tells the whole story. For example, if an increase in repeat abortions indicates more women are able to access an abortion when they need it, why don’t we celebrate that we might simply be meeting a previously unmet need rather than assume that women have become too carefree about abortion? Finally, I would suggest that the improvements abortion services have made in caring for women rather than stigmatising them might have led to more honest self-reporting of previous abortion. 

Until fairly recently, Primary Care Trusts (PCTs) rationed the number of abortions a woman could have and often treated women seeking abortion with anything from lack of compassion to downright contempt. Is it possible that removal of rationing and improvements in standards may simply have encouraged women more honestly to report their abortion history?

Lisa Hallgarten is director of Education For Choice. Read EFC’s blog for up-to-date news and comment on young people, sexual health and abortion from the UK and abroad. Follow EFC on TWITTER.

Also read:

UK: Controversy over teenage ‘repeat abortions’. Abortion Review, 18 June 2010

UK: Controversy over teenage ‘repeat abortions’

Government data have disclosed that 89 girls aged 17 or under who terminated a pregnancy last year had had at least two abortions previously, the Daily Telegraph reports. 

Christian doctors said the statistics demonstrated the failure of liberal sex education policies. Dr Peter Saunders, from the Christian Medical Fellowship, said that the figures were profoundly depressing.

‘It is increasingly clear that abortion is simply being used as a form of contraception by a growing percentage of girls and women, and that tired policies of values-free sex education, condoms and morning-after pills are not working,’ he said.

Statistics on ‘repeat abortions’ tend to cause controversy amongst some sections of the media. But such statistics, and claims about their significance, need to be handled sensibly. These figures have only been systematically collected for the last decade or so, and they are based on women’s self-reports of previous abortions. This means that, as abortion provision improves and the stigma associated with it decreases, women may be more likely both to have previous abortions and to report them.

The national abortion statistics for 2009 show that, for women of all ages, 34 per cent of abortions were performed on women who had had one or more previous abortions. This is a rise from 30 percent in 2000. As Dr Sam Rowlands notes in his contribution to the Abortion Review Special Edition: ‘Abortion and Women’s Lives’, this pattern is what might be expected, based on research across societies where abortion has been legal for some decades.

In relation to teenagers, the national statistics indicate a slightly different picture to the recent media reports. In 2009, for girls under the age of 18, 1,341 abortions were performed on women who had had one previous abortion: 8% of the total for that age group. The national statistics do not give any specific numbers for women aged under 18, or for those aged 18-24, who had had more than one previous abortion.

This does not mean that no teenagers have had previous abortions. It does mean that the numbers are difficult to verify, and in any case are likely to be small. The existence of ‘repeat abortions’ amongst girls under the age of 18 is therefore more likely to reflect their individual circumstances than it is any general social problem to do with sex education or promiscuity. As Ann Furedi, chief executive of BPAS, said, while teenage girls often feel able to handle sex, emotionally and physically, sometimes they struggle to handle the planning that comes with contraception.

Dozens of teenage girls have had three abortions or more. Daily Telegraph, 12 June 2010

Also read:

Teenagers and ‘repeat abortions’: contraception is not a magic bullet. Commentary by Lisa Hallgarten, director of Education For Choice. Abortion Review, 18 June 2010

Norway: Medical abortion at 63 to 90 days of gestation

The study set out to evaluate medical abortion as a treatment alternative for late first-trimester abortions and to evaluate the decrease in beta-hCG after abortion at 63-90 days of gestation. From Obstetrics and Gynecology. 

All women received mifepristone 200 mg orally, followed by 800 micrograms misoprostol vaginally 48 hours later. Misoprostol was repeated every 3 hours orally, to a maximum of five doses if needed. A clinical examination including ultrasonography was performed 8-14 days after treatment. beta-hCG level was determined before treatment and at follow-up.

A total of 254 pregnant women with gestational age 63 to 90 days were included. The successful termination rate was 91.7%. Surgical evacuation was carried out in 21 (8.3%) women. Most women (91.0%) found the method of treatment highly acceptable. The beta-hCG levels of women with successful termination had decreased more than 97.5% at follow-up.

The authors concluded that medical abortion is an effective and acceptable method for termination of pregnancy in late first trimester.

Department of Obstetrics and Gynecology, Haukeland University Hospital University of Bergen, Bergen, Norway.

Medical abortion at 63 to 90 days of gestation. Løkeland M, Iversen OE, Dahle GS, Nappen MH, Ertzeid L, Bjørge L. Obstetrics and Gynecology. 2010 May;115(5):962-8.

Keeping abortion decisions in context

Ann Furedi, writing in BioNews, examines the Sunday Times revelation that some assisted conceptions end in abortion.

The revelation in the UK’s Sunday Times newspaper (6 June 2010) that some assisted conceptions end in abortion was bound to cause consternation.

Increasingly, abortion has become accepted as a necessary back-up to contraception, essential to help women avoid unplanned, unintended pregnancies. But the abortion of carefully planned, deliberately conceived pregnancies does not fit into this framework of understanding. Human Fertilisation and Embryology Authority (HFEA) member Professor Bill Ledger seemed to represent, as he often does, the voice of common sense and reason when he observed that women whose conception is assisted, ‘can’t be surprised to be pregnant’, because, ‘you can’t have an IVF pregnancy by accident’.

When the Sunday Times contacted me for comment it was to discuss whether these abortions were a consequence of unscrupulous infertility doctors ‘rushing’ women into ill-considered treatment; a lack of counselling offered to women seeking treatment; or a sign of a ‘throwaway’ consumerist society where pregnancy might seen as nice one day and nasty the next.

But the explanation is obviously none of the above. The truth is that women who have help to become pregnant are still exposed to all the difficult stuff of life that blows ordinarily fertile women off their planned reproductive course.

People tend to overlook the complexities of reproductive decision-making faced by each couple in their own individual world of personal circumstances. We tend to categorise pregnancy neatly as ‘wanted’ or ‘unwanted’, ‘planned’ or ‘accidental’. In real life, things are rarely so clear. Some accidental pregnancies are welcomed. For some women, the fact that a pregnancy is intended and wanted at conception, does not mean that it will remain wanted as the weeks progress. Just as unintended pregnancies can, and do, become wanted. So planned, carefully-conceived pregnancies can become unwanted. The use of a technology to assist the conception does not protect it from this.

It is not unusual for BPAS clinics to see women requesting an end to a planned and wanted, naturally-conceived pregnancy that has turned into a life crisis. Sometimes the fetus is affected by a serious abnormality. But sometimes it is the woman’s life that changes so that she faces a totally different kind of motherhood to that she planned. Perhaps a relationship breaks down, the family loses its income, an existing child becomes ill, a parent requires care.

Assisted conception does not come with a guarantee that those who use it will be protected from all the problems that close in on the rest of us. On the contrary, assisted conception can bring extra pressures to bear on a relationship. Some couples claim their relationship is strengthened, others find it shattered.

For some women it is only when they find out they can conceive that they are able to consider whether a baby is what they want. The ‘crisis of choice’ is an issue that abortion providers are familiar with in a mirror-image context. Every clinic, every week, sees women who are adamant that an abortion is their only option, until the appointment is made, the theatre is prepared and they have the capacity to decide whether it is truly what they want. Then, the wanted end to the pregnancy becomes unwanted.

There is no scandal of post-IVF abortion that requires an Inquiry or investigation. The Sunday Times discovered that of 22,856 successful pregnancies following assisted conception just 0.7 per cent were terminated. This compares with around a quarter of all pregnancies which were conceived without help being terminated. This does not flag up warnings about poor quality care, or flippant consumerism. It highlights that for some women, a difficult reproductive journey continues even after a successfully achieved assisted conception. It should prompt us to appreciate all the more the complex and complicated decisions couples must make for themselves and why we should not rush to judge them.

This article first appeared in BioNews 562.

UK: Christmas advert revealed

Protestant Churches are joining forces in an advertising campaign that shows a scan of ‘baby Jesus in the Virgin Mary’s womb’, complete with halo, the Times (London) reports.

The poster campaign, which will feature on billboards nationally over Christmas, reads: ‘He’s on His way. Christmas starts with Christ.’

Created by advertising executives from the Church of England, Methodist, United Reformed and Baptist Churches, the campaign risks plunging Protestant Churches into the abortion debate with its imagery of an unborn child, the Times reports. The baby in the adverts is a composite made up of many baby scans.

The Roman Catholic Church, which opposes abortion, is not represented in ChurchAds.net.

John Smeaton, the director of the Society for the Protection of the Unborn Child, said:

‘This advertisement sends a powerful message to everyone in Britain where 570 babies are killed every day in the womb, 365 days a year, under the Abortion Act. Whenever we kill an unborn child in an abortion, we are killing Jesus. It may seem very early to be talking about Christmas, but we’d like to make this one of the largest church Christmas campaigns ever.’

Posters will not start appearing on bus stops until December 6, but will be available for purchase online. Terry Sanderson, of the National Secular Society, criticised the image.

‘I hope that the Church of England isn’t trying to use its Christmas poster campaign to make a political point. If that’s the intention, we may have questions to ask at the Charity Commission,’ he said. ‘If, on the other hand, it’s supposed to make a Christian Christmas more appealing to our secular nation, I think it is likely to have the opposite effect.’

Francis Goodwin, a founder member of ChurchAds.net, said:

‘This is the kind of thing proud parents-to-be show their friends and family — passing round the scan of the baby. Our poster reflects this new way of announcing the news of a new arrival and places the birth of Christ in an ultra-contemporary context. It offers a fresh perspective on the birth of Christ — creating anticipation and alluding to both His humanity and divinity.’

The Roman Catholic Church had an observer on ChurchAds.net, formerly the Church Advertising Network, but withdrew in 1996 in protest at a campaign that showed the Virgin Mary having a ‘bad hair day’ when she discovered that she was pregnant, the Times reports.

Protestant Churches risk abortion row with ‘Jesus scan’ advert. The Times (London), 9 June 2010

USA: Unborn children as constitutional persons

From Issues in Law and Medicine. 

The abstract reads:

In Roe v. Wade, the state of Texas argued that “the fetus is a ‘person’ within the language and meaning of the Fourteenth Amendment.” To which Justice Harry Blackmun responded, “If this suggestion of personhood is established, the appellant’s case, of course, collapses, for the fetus’ right to life would then be guaranteed specifically by the Amendment.”

However, Justice Blackmun then came to the conclusion “that the word ‘person,’ as used in the Fourteenth Amendment, does not include the unborn.” In this article, it is argued that unborn children are indeed “persons” within the language and meaning of the Fourteenth and Fifth Amendments. As there is no constitutional text explicitly holding unborn children to be, or not to be, “persons,” this argument will be based on the “historical understanding and practice, the structure of the Constitution, and thejurisprudence of [the Supreme] Court.”

Specifically, it is argued that the Constitution does not confer upon the federal government a specifically enumerated power to grant or deny “personhood” under the Fourteenth Amendment. Rather, the power to recognize or deny unborn children as the holders of rights and duties has been historically exercised by the states. The Roe opinion and other Supreme Court cases implicitly recognize this function of state sovereignty. The states did exercise this power and held unborn children to be persons under the property, tort, and criminal law of the several states at the time Roe was decided. As an effect of the unanimity of the states in holding unborn children to be persons under criminal, tort, and property law, the text of the Equal Protection Clause of the Fourteenth Amendment compels federal protection of unborn persons.

Furthermore, to the extent Justice Blackmun examined the substantive law in these disciplines, his findings are clearly erroneous and as a whole amount to judicial error. Moreover, as a matter of procedure, according to the due process standards recognized in Fifth Amendment jurisprudence of the Supreme Court, Roe v. Wade should be held null and void as to the rights and interests of unborn persons.

Unborn children as constitutional persons. Roden GJ. Issues in Law and Medicine. 2010 Spring;25(3):185-273.

Should women’s healthcare needs take priority over doctors’ beliefs?

Jennie Bristow, editor of Abortion Review, comments on an important new report on conscience and refusal clauses.

Health Care Refusals: Undermining Quality Care for Women, a report recently published by the US National Health Law Program’s Standards of Care Project examines the apparent proliferation of health care refusals based on ‘ideological and political justifications’, and their impact upon the health care received by women in the United States. (1)

The report notes that the ‘basic principles’ of modern health care delivery are ‘evidence-based practice, patient centeredness, and prevention’ – which, taken together, ensure quality care. The authors acknowledge that ‘these principles may be compromised by a range of structural factors such as lack of insurance, restricted geographic access, cost, language barriers, and immigration status’, and argue that current political movements are attempting to address these structural barriers. The recent debates over Barack Obama’s healthcare reform bill indicate that the high levels of sensitivity within the USA to the existing inequalities in access to healthcare, and the degree of political will that exists to address some of these.

However, the National Health Law Program argues that unlike these structural factors, ‘ideological restrictions are not being addressed in the current health care debate; they will not be resolved by current reform proposals; and, in fact, there is a serious risk that these restrictions will be institutionalised without careful evaluation of their public health impact’. Consequently, the report evaluates the potential impact on access to health care of ‘those health care refusals and denials of care rooted in political ideology or institutional or personal religious objections’.

The use of refusal clauses, or ‘conscience clauses’, to limit women’s access to reproductive healthcare is a problem that has gained increasing attention over the past few years. In the USA, it has been widely noted that the concept of ‘conscientious objection’ has expanded beyond its original intention – to prevent doctors from having to perform procedures, such as abortions, that conflict with their personal conscience. Now ‘conscience’ has been appropriated as a basis for refusal clauses by entire institutions, such as Catholic hospitals, and applied to a wider range of healthcare procedures, for example pharmacists refusing to fill prescriptions for contraception or emergency contraception, and doctors refusing to give fertility treatment.

Jon O’Brien, president of Catholics for Choice, has made a powerful argument against the trend for institutions to adopt the notion of ‘conscience’ as the basis for the practice of conscientious objections. Such institutions have, he states, ‘clearly gone beyond the bounds of exercising a reasonable conscience objection. Instead they are using the rhetoric of conscience to impose their morality on individuals, Catholic and non-Catholic alike, and depriving them of their right to conscience, as well as their right to a timely and complete medical service.’ (2)

The problem of ‘institutional’ conscientious objection has been less marked in the UK. But here too there have been issues raised in relation to pharmacists refusing to issue patients with medication prescribed by their doctors, and questions raised about the extent to which personal or religious beliefs may be accorded too much protection by the healthcare profession, when this has major consequences for the patient – such as unplanned pregnancy, resulting from the inability to access emergency contraception.

The report Health Care Refusals: Undermining Quality Care for Women provides a useful overview of the uses and possible abuses of refusal clauses in the USA, illustrated with some chilling examples of the negative health consequences that have faced women unable to access abortion or emergency contraception as a result. However, in challenging the use of conscience and refusal clauses, the report adopts a potentially difficult position, of prioritising women’s ‘right to health’ over and above judgements made by healthcare professionals on the basis of conscience and morality.

The report situates the growth of refusal clauses in the context of ‘political trends that have favoured ideology over science’. Its core argument is that medical treatment should follow standards based on scientific evidence about what is best for a patient’s health, and the principle that a patient should make their own decisions based on a process of ‘informed consent’. This is counterpoised to the ‘paternalistic’ model based on doctors’ judgements, which, in the view of the report’s authors, is what gives rise to the problematic use of refusal clauses.

The report’s authors explain their argument as follows:

‘Analyses of health care denials traditionally construct the issue as a conflict of rights within the provider-patient relationship: the health care provider’s right to exercise individual conscience vs. the patient’s right to exercise her autonomy. The question becomes how best to balance the rights and obligations within the relationship. This framework, while a common starting place, fails to attend to the special context in which the debate is occurring: health care. The moral contest framework fundamentally obscures the impact on patients’ health.’

They go on to explain that ‘health care is not like other fields’. The field is highly regulated, to protect patients from harm caused by untrained practitioners, and ‘the provider-patient relationship is inherently unequal’. In this context, the authors argue, the problem with focusing on ‘philosophical issues of balancing patients’ rights and providers’ beliefs’ is that this framing ‘fails to address the real life consequences refusals and denials of care have for patient health.’ They explain: 

‘Refocusing on medical quality and standards of care prioritises a patient’s health over the provider’s personal beliefs and raises the visibility of institutional policies that prohibit health professionals from providing certain care, even when they themselves do not object to such care.’

In other words, the authors seem to be arguing that the use of conscience clauses is problematic for two key reasons. Firstly, because of the inequality of the doctor-patient relationship, such clauses allow for an abuse of the clinician’s power, because ultimately it is his decision that will affect the health care that his patient can access. Secondly, because the consequences of refusing to treat a woman by, for example, performing an abortion when carrying the pregnancy to term will adversely affect her health, are grave and borne by the woman alone, her right to healthcare should trump the clinician’s right to exercise his conscience in relation to refusing treatment.

These are compelling arguments, and should certainly act as a warning against the promiscuous use of conscience or refusal clauses. But such arguments raise some difficult questions about how far it is acceptable to pose adherence scientific standards, or to patients’ wishes, as an approach that should necessarily take priority over a doctor’s individual conscience or even a healthcare institution’s value system.

Medicine is not a technical system, but a human practice. While science clearly provides the underpinning to medical practice, and standards and protocols are developed on the basis of clinical research, doctors – like their patients – are individuals, with their particular skills, attitudes and beliefs. To deny doctors the right to follow their consciences in relation to performing certain procedures, such as abortion or fertility treatment, would sideline this crucial human element of medicine. The goal of better health outcomes for women, and support for women’s choices, is a worthy one; but we do have to ask whether that justifies comprising a doctor’s personal sense of integrity and morality, and what might be lost by pushing doctors to practise against their core beliefs.

A similar argument could be made in relation to forcing a woman to have a procedure such as an abortion or a blood transfusion against her will, because it is the best thing for her health. In such cases, it is generally understood that scientific evidence is clear on the best course of action, and that a woman who refuses to follow this course of action may well die – but her ability to make that decision according to her own conscience is more critical than the fact of keeping her alive.

These are real-life situations in which the ‘philosophical’ discussions of rights and beliefs become crucial. To demand that a woman must obey the law of science when it comes to decisions about her own body would be received by many as uncomfortable. Yet this is the logical consequence of accepting that doctors should obey scientific evidence about what is best for health, even when it flies in the face of their own consciences. If it is accepted that scientific evidence operates in a different, higher, realm to human medicine, both the doctor and the patient find their autonomy compromised and their judgements impaired.

The use of refusal clauses by entire healthcare institutions, rather than individual doctors, raises a number of questions about women’s ability to access the treatment that they want and need. But again, for those attached to the principles of choice and liberty, there is something unpalatable about a notion that institutions should be somehow required to conduct procedures that run counter to their stated values. It would be unreasonable to expect an abortion clinic to employ a priest, so why would it be reasonable to expect a Catholic hospital to perform abortions?

The proliferation of refusal clauses in healthcare is not a benign development. Women forced to carrying pregnancies to term because they cannot find a doctor, or a healthcare institution, prepared to perform an abortion are denied the ability to control their fertility. In this context it is crucial that they are referred to doctors or institutions who will perform abortions – and reports such as that of the National Health Law Program are extremely valuable in indicating the extent to which referrals do not always happen, with serious consequences for the women affected.

But however frustrating it seems, the way to resolve the issue of doctors and institutions exercising their conscientious objection to abortion, contraception and fertility treatment will not be at the level of enforcing subservience to a scientific evidence base. It will be achieved by continuing to engage with principled debates about autonomy, rights, conscience and morality. If there are too many doctors and hospitals opting out of abortion provision, the onus is on those who support choice to make the moral case for abortion, and highlight the immorality of forcing women to carry unwanted pregnancies to term. 

(1) Health Care Refusals: Undermining Quality Care for Women. National Health Law Program Standards of Care Project, May 2010

(2) ‘Presenting the case for conscience’, by Jon O’Brien, in Abortion Review Special Edition 1: Abortion, Ethics, Conscience and Choice. Download this Special Edition for free here.

UK: About eighty IVF pregnancies per year end in abortion

Figures collected by the Human Fertilisation and Embryology Authority show that one per cent of assisted conceptions account for a tiny proportion of all abortions. 

The exact reasons for the terminations - which amount to an average of about 80 a year, or one percent of assisted conceptions - are unclear, but will include medical problems with the fetus as well as social grounds, such as a relationship breakdown, BBC News Online reports.

‘Selective reduction’ abortions, when one fetus is removed to improve the survival chances of another in a multiple pregnancy, are also included.

The figures from the Human Fertilisation and Embryology Authority, which regulates IVF clinics in the UK, were obtained as part of a Freedom of Information request. The story was originally published in the Sunday Times.

They show that the proportion of fetuses aborted remained stable between 1991 and 2008, the last year for which data was available. In that year there were 65 terminations in 6,723 pregnancies.

The 18-34 age group saw the highest number of abortions, with 23 terminations, but they also had significantly more pregnancies than older IVF patients.

There was no information on the number of abortions of IVF pregnancies which had originally been funded by the NHS. Public provision of IVF is patchy, and many couples pay thousands of pounds to undergo fertility procedures privately.

Professor Bill Ledger, a member of the HFEA said: ‘I had no idea that there were so many post-IVF abortions and each one is a tragedy’, while former conservative MP Ann Widdecombe said some were treating babies like ‘designer goods’.

But Susan Seenan of the Infertility Network UK advised caution.

‘Anyone who has undergone IVF knows what a long and difficult experience it can be. To make the decision to then terminate that pregnancy cannot be one that anyone takes lightly. I would imagine there are some pretty good reasons.’

Laura Riley, a spokesperson for the bpas, said:

‘Women and couples who have had donor insemination or IVF to become pregnant are unfortunately no more immune from the harsh vagaries of life than others who are lucky enough to be able to conceive naturally. Any woman can experience overwhelming life difficulties, such as intense relationship pressures or the diagnosis of a serious or lethal fetal medical problem. These may mean that she feels unable to continue with the pregnancy.’

There were 189,100 abortions in England and Wales in 2009, meaning that abortions following assisted conception account for 0.04% of all abortions.

80 IVF foetuses are aborted a year, figures show. BBC News Online, 7 June 2010

BPAS comment on HFEA statistics regarding abortion after licensed fertility treatment. Press release, 7 June 2010

UK: Reaction to TV abortion advert

The first television advert for abortion, broadcast by Marie Stopes International, has generated positive and negative responses. 

A post by Jennifer Howze on the Times’s Alpha Mummy blog has generated over 100 comments. Howze writes:

‘There has been loads of press about the new Marie Stopes ad, which shows pregnant woman who may or may not be contemplating abortions. The Times’s headline on its debut was entitled “Fury as TV advert for abortion advice gets the go-ahead”.

‘You’d think the ad showed women in sexy hospital gowns doing Glee-style song-and-dance numbers, with a chorus of “Have an abortion, they’re fun!” These critics must be the same kind of people who explode if the cook doesn’t hold the mayo on their burger or who yell out their car windows on the motorway. Most certainly they can’t be people who have ever had that moment where you think, “Oh my God I might be pregnant” and you don’t know what to do.

‘I’m so tired of the hysteria that surrounds even the discussion of abortion. This ad is a grown-up recognition of what can be a lonely, scary moment for a woman, and it talks to women like grown-ups. Could this really be an ad about unwanted pregnancy - no scolding, no paternalistic “there, there, dear”, no moral or emotional blackmail? It certainly doesn’t look like what you’d expect. It’s about time.’

Elsewhere, it has been reported that the Advertising Standards Authority has received 350 complaints from viewers offended by the commercial. The ASA will assess the complaints to see if there is grounds to investigate whether the TV commercial breached the advertising code.

The Christian Institute reports that ‘a group of MPs has called on the government to find out if any women have ever chosen to have their babies after being counselled by MSI, and how many of their patients are now suffering from post-abortion trauma’.

The call was made in an Early Day Motion presented by the Labour MP Jim Dobbin, and the Conservative MPs William Cash and Andrew Rosindell. The trio also expressed concern that the controversial ad was in breach of broadcast regulations, and they challenged the Advertising Standard Authority’s claim that the commercial isn’t advertising abortion.

The “controversial” abortion ad? You decide. Alpha Mummy, 27 May 2010

First UK ad for abortion services draws 350 complaints. Guardian, 28 May 2010

MPs criticise Marie Stopes over abortion commercial. The Christian Institute, 7 June 2010

USA: Palin calls for conservative, anti-abortion feminism

Sarah Palin, the former governor for Alaska, has provoked a barrange of commentary with her claims that women who oppose abortion rights are responsible for an ‘emerging, conservative, feminist identity’ and have the power to shape politics and elections around the issue. 

Speaking to a breakfast gathering of the Susan B. Anthony List in downtown Washington on 14 May, urged more than 500 audience members to back only those candidates for public office who are uncompromisingly opposed to abortion, the Washington Post reports.

The Susan B. Anthony List, a modest counterpart to the well-funded pro-abortion-rights Emily’s List, was founded in the early 1990s to elect antiabortion candidates, mostly women, to public office. The group is seeking to raise its profile with the passage of the federal health-care bill: Many antiabortion activists opposed the measure because it does not ban federal funding for abortions.

Palin, a potential 2012 presidential candidate, delivered calls to action to an audience dominated by women. ‘The mama grizzlies, they rise up,’ she said. ‘You thought pit bulls are tough. You don’t want to mess with the mama grizzlies. And I think there are a whole lot of those in this room.’

She described learning in 2007, after 12 weeks of pregnancy, that the child she was carrying had Down’s syndrome: ‘I said, “God, I don’t think I can handle this. This wasn’t part of my life’s plan“‘.

Palin went on to describe her now-2-year-old son Trig as her family’s ‘greatest blessing’, saying he was ‘God whispering in my ear, saying, “Are you going to trust me? Are you going to walk the walk or are you going to talk the talk?”’

Palin, whose teenage daughter Bristol is also a mother, criticised abortion rights advocates for delivering the message to young women that they don’t have the strength to go through with pregnancy and motherhood.

‘Our prominent woman sisterhood is telling these young women that they are strong enough to deal with this,’ Palin said. ‘They can give their child life, in addition to pursuing career and education and avocations. Society wants to tell these young women otherwise. These feminist groups want to tell these women that, “No, you’re not capable of doing both” ... It’s very hypocritical.’

In a widely-reproduced commentary on the speech, Jessica Valenti, author of The Purity Myth: How America’s Obsession With Virginity Is Hurting Young Women and the founder of Feministing.com, wrote in the Washington Post:

‘Palin’s sisterly speechifying is part of a larger conservative move to woo women by appropriating feminist language. Just as consumer culture tries to sell “Girls Gone Wild"-style sexism as “empowerment,” conservatives are trying to sell anti-women policies shrouded in pro-women rhetoric.

‘Several years ago, when anti-abortion protesters realized that screaming “Murderer!” at women wasn’t winning hearts and minds, they launched more palatable campaigns claiming that abortion hurts women—their new protest signs read “Women Deserve Better.” (Not surprisingly, this message is much more effective than spitting invective at emotionally vulnerable women)...’

Writing on the website DoubleX, Amanda Marcotte gives ‘A short history of “feminist” anti-feminists’:

‘There’s no real reason to consider Sarah Palin a feminist. She’s just the latest incarnation of a long and noble line of feminist anti-feminists: women who call themselves feminist but also object to the existence of the feminist movement and organize in opposition to it. Feminist anti-feminism has evolved in the shadow of feminism since the days when many women adamantly insisted they didn’t want or need the right to vote. And as feminism has morphed rapidly since the early days of the second wave, so has anti-feminism changed arguments and strategies, going through three distinct phases...’

Palin pushes abortion foes to form ‘conservative, feminist identity’. Washington Post, 15 May 2010

Sweden: Medical abortion in lactating women

The authors concluded that the levels of mifepristone in milk are low, and that breastfeeding can be safely continued in an uninterrupted manner during medical abortion of this kind. From Acta Obstetricia et Gynecologica Scandinavica. 

The authors noted that medical abortion using mifepristone followed by misoprostol is increasingly used for termination of an unwanted pregnancy. Consequently, an increasing number of women undergo medical abortion while still breastfeeding from a previous pregnancy. But there are no data on mifepristone use during lactation. The authors studied the levels of mifepristone in breast milk collected from women undergoing medical abortion.

Samples of milk were collected from 12 women during the first 7 days after intake of either 200 mg (n = 2) or 600 mg (n = 10) of mifepristone. In addition, serum samples were collected on day 3 (n = 4). The main outcome measures were the levels of mifepristone, quantified using radioimmunoassay.

The results found that the milk concentrations of mifepristone were highest in the first samples collected during the first 12 hours following drug intake, and ranged from undetectable (< 0.013 micromol/l) to 0.913 micromol/l. Thereafter, declining concentrations of mifepristone were detected up to 7 days. The lowest levels of mifepristone in milk were measured following ingestion of the 200 mg dose. The milk:serum ratio of mifepristone ranged from < 0.013:1 to 0.042:1 on day 3 (n = 4). The calculated relative infant dose (RID) was 1.5% at its highest.

The authors concluded that the levels of mifepristone in milk are low, especially when using the 200 mg dose. Breastfeeding can be safely continued in an uninterrupted manner during medical abortion of this kind.

Department of Woman and Child Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.

Medical abortion in lactating women--low levels of mifepristone in breast milk. Sääv I, Fiala C, Hämäläinen JM, Heikinheimo O, Gemzell-Danielsson K. Acta Obstetricia et Gynecologica Scandinavica. 2010 May;89(5):618-22.

Denmark: Termination of pregnancy for fetal anomaly after 23 weeks of gestation in Europe

The study set out to determine the prevalence of termination of pregnancy for fetal anomaly (TOPFA) after 23 weeks of gestation in European countries, and describe the spectrum of anomalies for which late TOPFA is recorded. From BJOG. 

This was a population-based study set in 12 European countries. The population was 19 registries of congenital anomaly in 12 European countries between 2000 and 2005. The number of total births covered was 2 695 832.

Methods: TOPFAs in singleton pregnancies from the European Surveillance of Congenital Anomalies and Twins (EUROCAT) database. The main outcome measures were the prevalence of TOPFA and type of anomaly.

The results found that there were 10 233 TOPFAs, 678 (6.6%) of which were performed at 24 weeks or more. The rate of TOPFA before 24 weeks was 3.4 per 1000 births, at 24-25 weeks 0.14 per 1000 births and at 26 weeks or more 0.11 per 1000 births. There was significant variation in the prevalence of TOPFA at >or=24 weeks between countries (P < 0.001), with all countries in the range 0-0.55 per 1000 births, except France (Paris) at 2.65 per 1000 births.

The large majority of late TOPFAs had a gestational age of 24-27 weeks (516/678, 76%). The proportion of TOPFAs from 24 weeks or more varied by type of anomaly, with 4% of all TOPFAs for chromosomal anomalies and 9% of all TOPFAs for nonchromosomal anomalies resulting in late TOPFA (P < 0.001). For transposition of the great arteries, single ventricle, hypoplastic left heart and hydrocephaly, the percentage of late TOPFA was 12-23%.

The median time interval between diagnosis and late TOPFA was 2 weeks for most anomalies, but longer (>or=5 weeks) for diaphragmatic hernia, omphalocoele, arthrogryposis multiplex and Turner’s syndrome.

The authors concluded that late TOPFA is rare in Europe, and varies in prevalence between countries. Compared with earlier TOPFA, late TOPFA is more often performed for a nonchromosomal isolated major structural anomaly and less often for a fetus with a chromosomal syndrome or multiple anomalies.

Hospital Lillebaelt, Kolding, Denmark.

Termination of pregnancy for fetal anomaly after 23 weeks of gestation: a European register-based study. Garne E, Khoshnood B, Loane M, Boyd P, Dolk H; EUROCAT Working Group. BJOG. 2010 May;117(6):660-6.

USA: Disparities in access to reproductive health options for female adolescents

The authors note that 50 percent of female adolescents in the United States have intercourse by age 17, yet they do not have the autonomy under the law to access reproductive healthcare services that can address and prevent the negative consequences often associated with adolescent involvement in sexual activity. From Social Work in Public Health. 

This article discusses disparities in access to reproductive health services for adolescents in three areas: abortion, over-the-counter emergency contraception, and the provision of the human papillomavirus vaccine.

Suggestions for advocacy efforts necessary to eliminate such health disparities are also presented in an effort to elevate female adolescents to a status where they have the same access to health services that are available to adult women.

College of Social Work, University of Kentucky, Lexington, Kentucky 40506-0027, USA.

Disparities in access to reproductive health options for female adolescents. Ely GE, Dulmus CN. Social Work in Public Health. 2010 May;25(3):341-51.

Northern Ireland: Anti-abortion campaigners challenge government guidelines

The Society for the Protection of Unborn Children (SPUC) has won permission to seek a judicial review of the controversial guidance. 

SPUC claims that the Department of Health breached an order for complete withdrawal of its guidance, BBC News Online reports.

The High Court ruled in 2009 that the advice on terminating pregnancies must be completely withdrawn because it was misleading.

A judge then rejected an attempt by the department to have just two sections on counselling and conscientious objection reconsidered rather than the full guidance.

SPUC has returned to court claiming Lord Justice Girvan’s direction has been breached by publishing guidelines with these parts omitted. The group also alleges there has been no proper consultation with it and other relevant parties.

SPUC originally wanted a declaration that what has been produced did not properly set out the law. It claimed the guidance also failed to deal with the rights of the unborn child and provided inadequate advice for conscientious objectors within the medical profession.

The Department of Health’s legal representatives rejected allegations it had failed to make clear that abortion was illegal in Northern Ireland apart from in the most exceptional circumstances. They also said the document was for health workers rather than the general public.

Although the High Court stopped short of quashing the guidelines, it ruled last year that the counselling and conscientious objection sections were unclear.

A date for the full hearing of the new challenge has yet to be set.

SPUC launches legal challenge to abortion guidelines. BBC News Online, 27 May 2010

Northern Ireland: Abortion law should change, gynaecologists suggest

A survey claims that the majority of gynaecologists in Northern Ireland ‘do not support the current abortion law as it stands’. 

Many also said they would carry out abortions under certain conditions, BBC News Online reports.

The survey, ‘Attitudes and practice of gynaecologists towards abortion in Northern Ireland’ (2009), was conducted by Colin Francome, Emeritus Professor in the Sociology of Health, at Middlesex University, England.

Of 42 gynaecologists working in Northern Ireland, 37 took part, giving a response rate of 88%.

Fifty-seven percent of respondents said they would support liberalising the current abortion law with more than two thirds agreeing that abortion should be legal on grounds of fetal abnormality.

Asked what conditions under which they would personally carry out abortions, 70% said they would be prepared to on grounds of fetal abnormality and 49% said they would where the woman has been raped.

The survey further sugggested that:

- 68% of NI gynaecologists agreed that abortion should be legal when the woman had been raped;

- 73% wanted free abortions for Northern Ireland women forced to travel overseas for the procedure;

- 51% supported major abortion charities being licensed to carry out abortions in Northern Ireland;

- Only 32% said the abortion law should stay as it is.

Colin Francome, who is also author of the 2004 book Abortion in the USA and the UK, said:

‘This is the second study I have carried out looking at the views of gynaecologists in Northern Ireland. This shows that the vast majority agree with the opinion that I also hold that the situation for women with an unwanted pregnancy is very unfair.’

Commenting on the survey’s findings, Dr Audrey Simpson OBE, Director of FPA Northern Ireland said:

‘A woman’s right to choose cannot continue to be ignored. It’s time to stop pretending that Northern Ireland women are different from women in the rest of the UK.  The simple fact is they are not. When faced with an unplanned or crisis pregnancy they deserve and have a right to access health care services that are freely available in the rest of the UK.’

The survey was published before the hearing on the 27 May in the Belfast High Court on whether the interim Guidance on termination of pregnancy: the law and clinical practice in Northern Ireland by the Department of Health, Social Services and Public Safety should be withdrawn. This is following a legal battle started by FPA in May 2001 to request the Department to issue guidelines regarding the provision of termination of pregnancy services in Northern Ireland.

Survey suggests easing of Northern Ireland abortion laws. BBC News Online, 26 May 2010

Liberalise the abortion law in Northern Ireland says over half of the country’s practising gynaecologists. fpa press release, 26 May 2010

UK: Abortion statistics show small decline

The abortion rate has dropped for the second year running in England and Wales, official statistics show.

But experts said it was still too early to say whether there was a downward trend, BBC News Online reports.

The total number of abortions was 189,100 in 2009 - a rate of 17.5 per 1,000 women aged 15 to 44. This compares to 18.2 in 2008, and comes after a general upward trend for the past 40 years which peaked in 2007.

The abortion rate in Scotland also fell last year to 12.4 per 1,000.

The statisitcs, released today by the Department of Health, show that in 2009, for women resident in England and Wales:

* The total number of abortions was 189,100,compared with 195,296 in 2008, a fall of 3.2%

* The age-standardised abortion rate was 17.5 per 1,000 resident women aged 15-44, compared with 18.2 in 2008

* The abortion rate was highest at 33 per 1,000, for women aged 19, 20 & 21, each lower than in 2008

* The under-16 abortion rate was 4.0 and the under-18 rate was 17.6 per 1,000 women, both lower than in 2008

* 94% of abortions were funded by the NHS; of these, over half (60%) took place in the independent sector under NHS contract

* 91% of abortions were carried out at under 13 weeks’ gestation; 75% were at under 10 weeks

* Medical abortions accounted for 40% of the total

* 2,085 abortions (1%) were under ground E, risk that the child would be born handicapped

* In 2009, there were 6,643 abortions for nonresidents carried out in hospitals and clinics in England and Wales (6,862 in 2008)

Ann Furedi, chief executive of BPAS, said:

‘It’s interesting to see that fewer abortions took place last year, for the second year running. However abortion figures tend to fluctuate slightly year-on-year so we can’t call this a trend yet, especially with the background of the last few decades’ gradual rise in the numbers of abortions.

‘We’re really pleased that a greater proportion of abortions took place at the earliest stages in 2009. There has been a 2% rise in the number of abortions at under of 10 weeks, which now make up three quarters of all abortions. In fact, 91% of all abortions were carried out at under 13 weeks of pregnancy. This probably indicates that better NHS funding has helped to build in more of the capacity needed to care for women when they need it.

‘There’s also been a lot of work done to improve women’s access to the most modern contraceptive methods, but we still know that the pill and condoms, the UK’s most commonly used contraceptives, have relatively high failure rates in typical use. Sex is also not always planned or prepared for, so it’s essential that the contraception and abortion services and the choice of methods offered reflect individual women’s needs.

‘Unintended pregnancy and abortion will always be facts of life, because women want to make sure the time is right for them to take on the important role of becoming a parent. Abortion statistics are reflective of women’s very serious consideration regarding that significant role within their current situation.’

Caution over abortion rate fall. BBC News Online, 25 May 2010

Abortion statistics, England and Wales: 2009. Department of Health, 25 May 2010

BPAS comments on new abortion statistics confirming a 3.2% fall in abortion numbers in England and Wales in 2009. BPAS, 25 May 2010

UK: New guidance published on advance provision of emergency contraception

The National Institute for Health and Clinical Excellence (NICE) recommends that pharmacies should offer the morning-after pill in advance, particularly for those under 25.

It is the first time that NICE has called for such a move as part of an attempt to improve access to all types of contraception, The Times (London) reports.

At present people are able to purchase emergency contraception over the counter at chemists, but it is normally given only after questions have confirmed that it is an emergency visit. A spokesperson for NICE said that the issue of whether women could buy in bulk had not been covered, and it would more likely be a single advance purchase.

NICE said that young men and women should also be able to access contraception, including condoms “in a range of types and sizes”, at convenient locations, such as schools and youth clubs.

The new guidance focuses on socially disadvantaged young people, for example, teenage parents, young people living in areas with high levels of deprivation, some minority ethnic groups, and young offenders. Its aim is that improving contraceptive services will ensure young people get the right support they need and help reduce unwanted pregnancies and abortion rates.

Dr Gillian Leng, NICE Deputy Chief Executive, said:

‘Although this guidance focuses on socially disadvantaged young people, key recommendations are also relevant to all young people, regardless of their background. This draft guidance responds to a real need to improve existing contraceptive services, making it easier for young people, especially the most disadvantaged, to get the right information, advice and treatment at the right time.’

Key draft recommendations include:

* Establish collaborative evidence-based commissioning arrangements between PCTs to provide contraception and sexual health services for young people at convenient, accessible locations such as city centres, colleges and schools so that no young person is denied services because of where they live.

* Doctors, nurses and pharmacists should where possible, provide the full range of contraceptive methods, especially long-acting reversible contraception (LARC), condoms to prevent transmission of STIs and emergency contraception (both hormonal and timely insertion of an intrauterine device).

* Provide additional support for disadvantaged young people to enable them to gain access to contraceptive services without delay and to support them as necessary in using the service (for example, access to interpreters, one-to-one support, facilities for people with physical and sensory disabilities, and assistance for those with learning disabilities).

* Ensure all young women are able to obtain free emergency hormonal contraception, including advance provision.

* Ensure young men and young women know where to obtain free advance provision of emergency hormonal contraception.

* In addition to providing emergency hormonal contraception, professionals should ensure that all young women who obtain emergency hormonal contraception are offered clear information about, and referral to, contraception and sexual health services.

* Encourage all young people to use condoms and lubricant in every encounter, irrespective of their other contraceptive choices, because condoms help to prevent the transmission of sexually transmitted infections.

Ann Furedi, chief executive of BPAS, said: 

‘The aims of this draft guidance are excellent and ambitious, but there’s a long way to go to make many of these recommendations a reality.’

She continued:

‘Women often tell us that in the pharmacy, there can be reluctance, or even refusal on the part of pharmacists to dispense the “morning after pill” when they ask for an advance supply. This is an urgent time-sensitive treatment, most effective at preventing pregnancy within the first 12 hours after unprotected sex. This is a serious training issue, as there are no rules to prevent EC being made available in advance by pharmacists, and indeed their regulatory body is supportive of this.

‘The cost of EC is especially pertinent to young and disadvantaged people, who are amog the least likely to be able to pay out close to £30 at short notice for the “morning after pill” over a pharmacy counter. Certainly not every PCT funds free emergency contraception to young people in advance from locations they can easily access, including, shockingly, also in the case of emergency need. There is much more work to do to make sure this backup option is genuinely accessible to all young people if their regular contraceptive method has failed, or the couple failed to use it.’

Be ready for the morning after - get the Pill before. The Times (London), 25 May 2010

NICE seeks to reduce unwanted pregnancies by improving contraceptive services. National Institute for Clinical Excellence, 25 May 2010

AR update, 25 May 2010

UK abortion statistics show small decline; new guidance published on advance provision of emergency contraception; Cochrane review on cervical preparation for first trimester surgical abortion; a comparison of transabdominal and transvaginal ultrasonography in Early Medical Abortion, and more…

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This news digest is sent by email to those who have signed up to the Abortion Review Online mailing list. To join the mailing list for free, see here.

A quarterly news digest is provided in the print edition of Abortion Review. You can download the print edition for free here.

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- 1. UK ABORTION STATISTICS SHOW SMALL DECLINE

The total number of abortions in England and Wales was 189,100 in 2009, compared with 195,296 in 2008, a fall of 3.2%. The age-standardised abortion rate was 17.5 per 1,000 resident women aged 15-44, compared with 18.2 in 2008.

In 2009, 91% of abortions were carried out at under 13 weeks’ gestation; 75% were at under 10 weeks.

Ann Furedi, chief executive of BPAS, said:

‘It’s interesting to see that fewer abortions took place last year, for the second year running. However abortion figures tend to fluctuate slightly year-on-year so we can’t call this a trend yet, especially with the background of the last few decades’ gradual rise in the numbers of abortions.

‘We’re really pleased that a greater proportion of abortions took place at the earliest stages in 2009. There has been a 2% rise in the number of abortions at under 10 weeks. This probably indicates that better NHS funding has helped to build in more of the capacity needed to care for women when they need it.

‘There’s also been a lot of work done to improve women’s access to the most modern contraceptive methods, but we still know that the pill and condoms, the UK’s most commonly used contraceptives, have relatively high failure rates in typical use. Sex is also not always planned or prepared for, so it’s essential that the contraception and abortion services and the choice of methods offered reflect individual women’s needs.

‘Unintended pregnancy and abortion will always be facts of life, because women want to make sure the time is right for them to take on the important role of becoming a parent. Abortion statistics are reflective of women’s very serious consideration regarding that significant role within their current situation.’

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ALSO NEW ON ABORTION REVIEW

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- 2. NEW GUIDANCE PUBLISHED ON ADVANCE PROVISION OF EMERGENCY CONTRACEPTION

The National Institute for Health and Clinical Excellence (NICE) recommends that pharmacies should offer the morning-after pill in advance, particularly for those under 25.

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- 3. CLINICAL UPDATE: HOME MANAGEMENT OF EARLY MEDICAL ABORTION

By Patricia Lohr, Medical Director, BPAS.

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Patricia Lohr’s Clinical Update column appears in the Summer 2010 print edition of Abortion Review. Download a .pdf of the print edition for free here.

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- 4. USA: OKLAHOMA PASSES RESTRICTIVE NEW LAW

The US state of Oklahoma requires women to undergo an ultrasound scan just an hour before having an abortion. 

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- 5. REACTIONS TO 50TH ANNIVERSARY OF THE PILL

The Hollywood actress Raquel Welch has blamed the widespread use of oral contraceptives for a breakdown in sexual morality, while others celebrate the liberating effects of safe and effective contraception.

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- 6. UK: CONTROVERSY OVER MSI’S TELEVISION AD

An advertisement by an abortion advisory organisation has been screened for the first time on UK television, to opposition from anti-abortion campaigners.

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MEDICAL UPDATE

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- 7. WHO: CERVICAL PREPARATION FOR FIRST TRIMESTER SURGICAL ABORTION

This review set out to determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred. From the Cochrane Database of Systematic Reviews.

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- 8. UK: A COMPARISON OF TRANSABDOMINAL AND TRANSVAGINAL ULTRASONOGRAPHY IN EARLY MEDICAL ABORTION

The authors sought to establish the accuracy of abdominal ultrasonography in determining gestational age and identifying the presence of a gestational sac and embryonic pole before and after medical abortion. From Contraception. 

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- 9. USA: RISK OF MISCARRIAGE WITH BIVALENT VACCINE AGAINST HUMAN PAPILLOMAVIRUS (HPV) TYPES 16 AND 18

The authors concluded that there is no evidence overall for an association between HPV vaccination and risk of miscarriage. From the British Medical Journal.

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- 10. TAIWAN: SONOGRAPHIC QUANTIFICATION OF ENDOMETRIAL CHANGES AFTER ABORTION

The study set out to examine the diagnostic feasibility of sonographic gray scale histograms to assess changes in the endometrium following abortion induced by mifepristone and misoprostol. From Acta Obstetricia et Gynecologica Scandinavica. 

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EVENT

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- 11. PREGNANCY AND PREGNANCY PLANNING IN THE NEW PARENTING CULTURE

This two day seminar in June, organised by Parenting Culture Studies and the Kent Centre for Law Gender and Sexuality at the University of Kent, UK, and supported by BPAS and the Economic and Social Research Council, will discuss the relationship between reproductive autonomy and a culture of ‘intensive parenting’.

Speakers include:

-- KRISTIN LUKER, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology, University of California: ‘Abortion and the politics of motherhood revisited’

-- RACHEL JONES, Senior Research Associate, Guttmacher Institute, New York: ‘Abortion decision making in a culture of “intensive motherhood“‘

-- DANIELLE BASSETT, Charlotte Ellertson Social Science Postdoctoral Fellow, Ibis Reproductive Health, Cambridge, MA: ‘Pregnancy after abortion: women’s experiences of a stigmatised reproductive career’

Places are limited, so early booking is advised. For details, see here.

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For news updates from the UK, see here.

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For news updates from around the world, see here.

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For updates from the medical press, see here.

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Misoprostol to terminate pregnancy in the second or third trimester

The study’s objectives were to compare the benefits and harms of misoprostol to induce labour to terminate pregnancy in the second and third trimester for women with a fetal anomaly or after intrauterine fetal death when compared with other methods of induction of labour. From Cochrane Database of Systematic Reviews. 

The authors note that a woman may need to give birth prior to the spontaneous onset of labour in situations where the fetus has died in utero (also called a stillbirth), or for the termination of pregnancy where the fetus, if born alive would not survive or would have a permanent handicap. Misoprostol is a prostaglandin medication that can be used to induce labour in these situations.

The study’s objectives were to compare the benefits and harms of misoprostol to induce labour to terminate pregnancy in the second and third trimester for women with a fetal anomaly or after intrauterine fetal death when compared with other methods of induction of labour.

The authors searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (November 2009). The selection criteria were randomised controlled trials comparing misoprostol with placebo or no treatment, or any other method of induction of labour, for women undergoing induction of labour to terminate pregnancy in the second and third trimester following an intrauterine fetal death or for fetal anomalies. Both authors independently assessed trial quality and extracted data.

The authors included 38 studies (3679 women). Nine studies included pregnancies after intrauterine deaths, five studies included termination of pregnancies because of fetal anomalies when the fetus was still alive and the rest (24) presented the pooled data for intrauterine deaths, fetal anomalies and social reasons.When compared with agents that have traditionally been used to induce labour in this setting (for example, gemeprost, prostaglandin E(2) and prostaglandin F(2alpha)), vaginal misoprostol is as effective in ensuring vaginal birth within 24 hours, with a similar induction to birth interval.

Vaginal misoprostol is associated with a reduction in the occurrence of maternal gastrointestinal side effects such as nausea, vomiting and diarrhoea when compared with other prostaglandin preparations. While the different treatments involving various prostaglandin preparations appear comparable for the reported outcomes, the information available regarding rare maternal complications, such as uterine rupture, is limited.

The authors concluded that the use of vaginal misoprostol in the termination of second and third trimester of pregnancy is as effective as other prostaglandin preparations (including cervagem, prostaglandin E(2) and prostaglandin F(2alpha)), and more effective than oral administration of misoprostol. However, important information regarding maternal safety, and in particular the occurrence of rare outcomes such as uterine rupture, remains limited. Future research efforts should be directed towards determining the optimal dose and frequency of administration, with particular attention to standardised reporting of all relevant outcomes and assessment of rare adverse events. Further information is required about the use of sublingual misoprostol in this setting.

School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women’s and Children’s Hospital, 72 King William Road, Adelaide, South Australia, Australia, 5006.

Misoprostol for induction of labour to terminate pregnancy in the second or third trimester for women with a fetal anomaly or after intrauterine fetal death. Dodd JM, Crowther CA. Cochrane Database of Systematic Reviews. 2010 Apr 14;4:CD004901.

Clinical Update: Home management of Early Medical Abortion

By Patricia Lohr, Medical Director, BPAS.

This Q&A is based on the study ‘Women’s opinions on the home management of early medical abortion in the UK’, by Patricia Lohr and colleagues, published in the Journal of Family Planning and Reproductive Health Care 2010: 36(1) 21. The full study is available here.

Patricia Lohr’s Q&A appears in the Summer 2010 print edition of Abortion Review. Download a .pdf of the print edition here.

Q) What is the situation regarding the home management of early medical abortion in the UK?

Under the 1967 Abortion Act, any treatment for abortion has to be carried out in a hospital or a place approved for this purpose by the Secretary of State (1). The Department of Health currently interprets this as meaning that both medications used for early medical abortion (EMA) – mifepristone
and misoprostol - must be given in an authorised medical facility.

Practically, this means women must make a separate visit to receive each medication in addition to their consultation and follow-up appointments. Many hospital-based services admit women to the wards after administering misoprostol (2), but most independent abortion providers, like BPAS, discharge women after misoprostol administration to complete the process at home.

This service development occurred in response to clients’ requests to go home and with the knowledge from studies in other countries that completing an early medical abortion at home was safe and acceptable.

Q) What was the purpose of this study?

There hasn’t been much research in the UK on the home management of EMA so we felt it was important to find out women’s opinions and experiences of this service. We invited all eligible women undergoing EMA at any BPAS clinic during a two-week period to take part. One week after the administration of misoprostol, we contacted them by telephone and asked them to answer a short structured questionnaire.

We also included one open-ended question to give women the opportunity to add other comments.

Q) What did the results find?

We surveyed 162 women and found that most (86%) would rather go home to complete an EMA than remain at the clinic. The majority (96%) found home management very or somewhat acceptable and 96% felt they could have obtained medical help easily if necessary. Most respondents (62%) would prefer home use of misoprostol as opposed to returning to the clinic to obtain and use the medication.

The study also found that Asian women, or those with a gestational age of greater than 49 days, were less likely to prefer home management than others in the sample.

Q) What reasons did women give for their preference?

We didn’t specifically ask women about the reasons behind their preferences. However, in the open-ended question many women chose to comment on the meaning that being at home had for them. They described it as a good experience, commenting on the benefit of being in ‘my own space’, and using words such as ‘right’, ‘comfortable’, ‘relaxed’, ‘convenient’ and ‘private’.

Interestingly, 21% of the women who provided qualitative comments remarked on the difficulty of the journey home after misoprostol administration. They described it as inconvenient or noted that they were very concerned about experiencing symptoms before they got home. Some even commented that they began to have bleeding or cramping on the journey home. However, rather than encouraging them to stay in the clinic for the duration of the abortion, these experiences appeared to increase their support for the idea that misoprostol could be used at home. As one woman said: ‘I felt so anxious because I really felt that I had to hurry home. I would much rather have been able to do the second medicine in the comfort of my own home’.

Relatively smaller numbers of women gave reasons why they would prefer to stay in the clinic, such as reassurance that the abortion was proceeding as expected, or that they were concerned about things that were unexpected, such as variability in the time to complete the abortion. And a few women also took the opportunity to tell us that they felt that the decision to have home management should be an individual choice, emphasising that the option should be available for everyone, even if some choose not to take it.

Q) How does this study relate to others in the UK?

In many countries, home use of misoprostol is routine, and several studies show that it is safe and highly acceptable (3–7). In the UK, however, the restriction on home use means that information about women’s opinions of this practice is limited. One 1992 study in Edinburgh found that only 24% of 180 women who had experienced a medical abortion in a clinical setting would prefer to have the abortion at home. (8)

In 2005, Hamoda et al. surveyed 366 women in four hospital-based services in England and Scotland, all of whom remained in this setting after the administration of misoprostol but were asked for their views on the hypothetical situation of having a medical abortion at home. (9) Seventy-one per cent of respondents reported that there was nothing during their stay in hospital that they could not have managed on their own; nonetheless, only 36% would have opted for a home EMA.

Different findings came out of a clinical trial in Aberdeen in 2005, in which 49 women up to 56 days’ gestation were treated with 200mg oral mifepristone in a clinical setting followed by self-administration of 600 μg sublingual misoprostol 36–48 hours later at home. (10) Forty-five participants returned study questionnaires about their experiences and opinions: most (96%) were very satisfied or satisfied with home EMA, and 93% stated they would opt for medical abortion at home if necessary in future. Our finding of a high acceptability of home management of EMA is similar to this study, perhaps because it reflects the opinions of women who have safely and satisfactorily experienced a medical abortion outside of a clinical setting.

Q) What are the practical implications of this study?

The limited amount of information about women’s opinions on home management of EMA in the UK, and the differences found by those studies that do exist, means that those designing abortion services need to take care not to assume women’s preferences. Some women express a strong preference for managing their abortion at home, and it is important to manage their expectations and provide adequate support services such as a 24-hour telephone advice line. Other women may prefer to stay in the clinic, and giving women this option is reasonable if resources allow it.

However, our study does indicate, in line with research from other countries where home use of misoprostol is routine, that many women find managing their abortion at home highly acceptable, and voice a preference for administering misoprostol at home rather than having to do so in the clinic. My view is that EMA provision in the UK would be improved, and further research into this area permitted, if consideration were given to updating the interpretation of the UK’s abortion law to allow home administration of misoprostol.

References

(10) Hamoda H, Ashok PW, Flett GMM, Templeton A. Home selfadministration of misoprostol for medical abortion up to 56 days’ gestation. Journal of Family Planning and Reproductive Health Care 2005; 31:189–192.

UK: Flexible mifepristone and misoprostol administration interval for first-trimester abortion

This was a systematic review of randomized controlled trials published from 1999 to 2008 to assess the evidence for a shorter mifepristone and misoprostol administration interval at first trimester medical termination. From Contraception. 

The authors note that the administration interval between mifepristone and misoprostol is usually about 36-48 h, which might affect a woman’s choice of method of termination. Unwanted outcomes such as uterine bleeding, painful cramps and psychosocial issues which may occur during this long interval can be altered by a shorter administration interval.

A shorter interval will be cost-effective as it saves both women’s and clinician’s time and other resources. If the waiting time interval between therapeutic interventions could be reduced without compromising efficacy, it will potentially improve compliance, patient acceptability and quality of care.

This was a systematic review of randomized controlled trials published from 1999 to 2008 was conducted to assess the evidence for a shorter mifepristone and misoprostol administration interval at first trimester medical termination. Searching strategy included MEDLINE, EMBASE, CLINAHL and Cochrane Library. The primary outcome measure was complete abortion without the need for a surgical procedure.

Five randomized controlled trials (RCT) compared the efficacy of mifepristone and misoprostol administration intervals between 0 and 72 h in 5139 participants. The complete abortion rates varied between 90% and 98%. Although the meta-analysis of pooled data of all RCTs shows no statistically significant difference in efficacy between the shorter and longer dosing intervals, there is a trend toward slightly lower success rates with administration intervals earlier than 8 h.

The authors concluded that overall efficacy of complete abortion is not statistically different between the longer and shorter administration intervals. This might encourage the clinician to adopt a ‘flexible policy’ with fully informed consent and consideration of all circumstances.

Department of Obstetrics and Gynaecology, Glasgow Royal Infirmary, Glasgow, UK.

Flexible mifepristone and misoprostol administration interval for first-trimester medical termination. Wedisinghe L, Elsandabesee D. Contraception. 2010 Apr;81(4):269-74. Epub 2009 Oct 29.

Tunisia: Two medical abortion regimens for late first-trimester termination of pregnancy

The authors concluded that for late first-trimester termination, a single 800-mcg vaginal dose of misoprostol seems to be as effective as the mifepristone+misoprostol regimen, with acceptable side effects. From Contraception. 

The authors noted that medical abortion regimens based on the use of either misoprostol alone or in association with mifepristone have shown high efficacy and excellent safety profile in early pregnancy abortion. However, no clear recommendation is available for late first-trimester termination of pregnancy.

This was a prospective randomized controlled trial included 122 women seeking medical abortion at 9 to 12 weeks of gestation. Seventy-three patients were given a fixed protocol of 200 mg of mifepristone followed 48 h later by 400 mcg oral misoprostol (Group 1). The second group of 49 patients was administered 800-mcg intravaginal single-dose misoprostol (Group 2). This study sought to compare safety, efficacy and acceptability of these two nonsurgical abortion regimens.

The results found that 59 (80.8%) women in Group 1 had complete abortion vs. 38 (77.4%) women in Group 2 (p=.66). Abdominal pain was observed significantly more often in Group 2 (35/49 (71.4%) vs. 32/73 (43.8%) in Group 1, p<.0001. Medical abortion was equally acceptable among the two groups [37/49 (75.5%) and 55/73 (75.7%), p=.89].

The authors concluded that for late first-trimester termination, a single 800-mcg vaginal dose of misoprostol seems to be as effective as the mifepristone+misoprostol regimen, with acceptable side effects.

Department A of Obstetrics and Gynecology, Tunisian Maternity and Neonatology Center, Rabta, Tunis, Tunisia.

Two medical abortion regimens for late first-trimester termination of pregnancy: a prospective randomized trial. Dalenda C, Ines N, Fathia B, Malika A, Bechir Z, Ezzeddine S, Hela C, Badis CM. Contraception. 2010 Apr;81(4):323-7. Epub 2010 Jan 15.

China: Mifepristone-induced abortion and duration of third stage labour in a subsequent pregnancy

The study did not provide evidence that one mifepristone-induced abortion was associated with the risk of prolonged third stage of labour in a subsequent pregnancy in primiparae. From Paediatric and Perinatal Epidemiology. 

To evaluate the impact of mifepristone-induced abortion (MA) on the duration of third stage labour in a subsequent pregnancy, an observational cohort study was conducted from 1998 to 2001 at antenatal clinics in Shanghai, Beijing and Chengdu, China.

A total of 4925 pregnant women with no history of induced abortion (NA) and 4931 pregnant women with one previous MA were enrolled and followed until delivery. Of these, 5139 women who delivered singletons vaginally were used in the present analyses, including 2614 with NA and 2525 with a history of MA. Maternal characteristics, labour duration and other obstetric and gynaecological information were obtained.

The incidence rates of prolonged third stage of labour were 1.55% and 1.49% in NA and MA, respectively. After adjusting for age at delivery, maternal education, maternal occupation, area of residence, duration of gestational, type of delivery and pregnancy-induced hypertension, MA was not associated with the risk of prolonged third stage of labour (odds ratios = 0.92, 95% confidence interval 0.58, 1.44). Subgroup analysis of women with MA showed similar results regardless of gestational age at abortion, woman’s age at abortion, subsequent curettage/complications and the interpregnancy interval.

In conclusion, the data did not provide evidence that one MA was associated with the risk of prolonged third stage of labour in a subsequent pregnancy in primiparae.

Department of Reproductive Epidemiology and Social Science, National Population and Family Planning Key Laboratory of Contraceptive Drugs and Devices, Shanghai Institute of Planned Parenthood Research, Shanghai, China.

Mifepristone-induced abortion and duration of third stage labour in a subsequent pregnancy. Miao MH, Gao ES, Chen AM, Luo L, Cheng YM, Yuan W. Paediatric and Perinatal Epidemiology. 2010 Mar;24(2):125-30.

USA: Intrauterine contraceptives: a review of uses, side effects, and candidates

This article reviews the two intrauterine devices (IUDs) available in the United States. From Seminars in Reproductive Medicine. 

This article reviews the two intrauterine devices (IUDs) available in the United States: the TCu380A, marketed as ParaGard (Duramed Pharmaceuticals, Inc. Pomona, NY), and the levonorgestrel-releasing intrauterine system (LNG-IUS), marketed as Mirena (Bayer HealthCare Pharmaceuticals, Inc., Wayne, NJ). The properties of the two devices are detailed, as well as noncontraceptive indications and appropriate candidates for use.

The author notes that studies consistently demonstrate that the devices are safe, effective, and provide cost savings when compared with other reversible methods. The TCu380A may be used as postcoital contraception with close to 100% effectiveness. Menstrual blood loss is likely to increase with the TCu380A and decrease with the LNG-IUS. Reduction in menstrual blood loss and endometrial suppression make the LNG-IUS an increasingly popular treatment for menorrhagia, endometriosis, adenomyosis, and as an adjunct to estrogen therapy.

IUDs may be inserted immediately after a first- or second-trimester abortion, immediately postpartum, and >or=4 weeks postpartum. Candidacy for IUDs has expanded, and includes nulliparous women, adolescents, and women with immunocompromised conditions including HIV.

Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York 10032, USA.

Intrauterine contraceptives: a review of uses, side effects, and candidates. Shimoni N. Seminars in Reproductive Medicine. 2010 Mar;28(2):118-25. Epub 2010 Mar 29.

UK: Controversy over MSI’s television ad

An advertisement by an abortion advisory organisation is to be screened for the first time on UK television.

The campaign for unplanned pregnancy and abortion advice at Marie Stopes clinics will raise awareness of sexual health, the organisation said.

The 30-second film to be shown on Channel 4 will first air at 2210 BST on 24 May and run until the end of June, BBC News Online reports.

The advertisement asks ‘Are you late?’ and points those facing an unplanned pregnancy to Marie Stopes International’s 24-hour helpline. The organisation says callers ‘can receive non-judgemental support, advice and services’.

Marie Stopes chief executive Dana Hovig said:

‘Last year alone we received 350,000 calls to our 24-hour helpline. Clearly there are hundreds of thousands of women who want and need sexual health information and advice and access to services. We hope the new “Are you late?” campaign will encourage people to talk about their choices, including abortion, more openly and honestly, and empower women to reach confident, informed decisions about their sexual health.’

Michaela Aston, a spokeswoman for anti-abortion charity Life, said:

‘To allow abortion providers to advertise on TV, as though they were no different from car companies or detergent manufacturers, is grotesque. By suggesting that abortion is yet another consumer choice, it trivialises human life and completely contravenes the spirit of the 1967 Abortion Act, which was supposed to allow for a small number of legal abortions in a limited number of hard cases, but has been twisted and distorted to allow for mass abortion on demand.’

The Society for the Protection of Unborn Children said it was taking advice on the legality of the advertisement. It called on the culture secretary to make regulator Ofcom impose restrictions on such broadcasts.

The first advert for Marie Stopes, which is a not-for-profit organisation, will be shown during the Million Pound Drop Live game show hosted by Davina McCall. Marie Stopes said about 80% of the abortions it provided in 2009 were funded by the NHS.

The Advertising Standards Authority (ASA) said non-commercial providers of post-conception advice services had long been permitted to run advertisements.

An ASA spokesman said:

‘Any ad that airs has to comply with all the relevant rules in the Advertising Code, which aims to ensure that ads are not misleading and socially responsible. Ads must adhere to rules that are designed to protect children and vulnerable groups and prevent ads from causing serious or widespread offence. TV ads are checked against the rules before they are broadcast. If viewers have concerns about the content or scheduling of the ad, the ASA is able to consider complaints once the ad has aired.’

Ann Furedi, Chief Executive of BPAS, said:

‘We welcome the television advertising of pregnancy advisory services. These stigmatised and marginalised services can be crucially important for the women that need them at a stressful time in their lives. It’s nice to see a greater awareness of these services being brought into the mainstream.’

Abortion advice organisation Marie Stopes to air TV ad. BBC News Online, 20 May 2010.

Also read:

UK: Fewer restrictions on TV condom ads. Abortion Review, 24 March 2010

USA: Reactions to 50th anniversary of the Pill

The Hollywood actress Raquel Welch has blamed the widespread use of oral contraceptives for a breakdown in sexual morality, while others celebrate the liberating effects of safe and effective contraception.

Miss Welch, 69, said the situation has grown so grave that ‘these days nobody seems able to keep it in their pants or honour a commitment’, the UK Daily Mail reports.

While she argued that it carried some benefits, she said the enduring legacy of the Pill has been social anarchy.

Miss Welch has been a sex symbol since she sprang to international fame for her role in the 1966 film One Million Years BC - and was voted by readers of Playboy magazine as ‘the most desired female of the 1970s’. But in an article to mark the introduction of the Pill to the US market 50 years ago, she distanced herself from the fruits of the sexual revolution of which she was a part.

‘The growing proliferation of birth control methods has had an awesome effect on both sexes and led to a sea change in moral values,’ she said in an article for television channel CNN entitled ‘It’s SexO’Clock in America’.

A positive consequence of the Pill was it had ‘made it easier for a woman to choose to delay having children until after she established herself in a career’, she said.

Miss Welch, who has three failed marriages behind her, added that a ‘significant and enduring’ effect on women was the idea that they could have sex without any consequences - with the result that fewer today saw marriage as a ‘viable option’.

She went on: ‘Seriously, folks, if an ageing sex symbol like me starts waving the red flag of caution over how low moral standards have plummeted, you know it’s gotta be pretty bad.’

Two articles published on RH Reality Check took a more positive approach.

Sarah Seltzer wrote, ‘The 50th anniversary of the birth control pill has brought a lot of complaining about its lack of perfection. Still, for many women, it remains utterly liberating and effectively keeps its satisfied users from the whole “biology is destiny” thing’.

Elizabeth Gregory argued, ‘The birth control pill helped redefine the dynamics of motherhood and transform the lives of women, men and their kids, both physically and socially’.

In the UK Clare Murphy, health reporter for BBC News, gives a compelling overview of how ‘half a century on, our relationship with the tablet credited with revolutionising women’s lives is not always an easy one’.

The Pill ruined the institution of marriage, says Raquel Welch. Daily Mail, 11 May 2010

In Defense of the Pill and in Favor of Improving It. By Sarah Seltzer. RH Reality Check, 11 May 2010

Planning Motherhood: The Pill and the Social Transformations it Helped Us Realize. By Elizabeth Gregory. RH Reality Check, 11 May 2010

50 years of a sometimes bitter pill. By Clare Murphy. BBC News Online, 7 May 2010

USA: Oklahoma passes restrictive new law

The US state of Oklahoma requires women to undergo an ultrasound scan just an hour before having an abortion. 

Even women who are victims of rape or incest will be required to view the image prior to the procedure and listen to a detailed description of what can be seen, the UK Daily Telegraph reports.

They would also be given vaginal rather than abdominal ultrasounds as doctors are required to use the method that ‘would display the embryo or fetus more clearly’.

The laws, which were immediately challenged by pro-choice groups, also allow doctors to withhold test results showing fetal defects.

The second bill shielded doctors from lawsuits by parents with disabled children who may have chosen to have an abortion if they had they been informed about genetic or other defects. Opponents argued that doctors who want to withhold information because of their own beliefs would now be protected by law.

The Centre for Reproductive Rights has filed a lawsuit claiming the ultrasound law breaks the state’s constitution on multiple grounds.

Nancy Northup, the president, said: ‘That is shocking, because women expect doctors to provide them with full information about their pregnancy’. The new requirement, she said, ‘profoundly intrudes upon a patient’s privacy and violates free speech rights by forcing patients to listen to information unnecessary for medical care’.

Abortion has been allowed in the USA since the 1973 Roe V Wade decision in the Supreme Court, which ruled on the basis of a women’s right to privacy that states could not prohibit access to abortions prior to fetal viability, generally seen to be somewhere around 24 weeks, or when the pregnancy threatened the woman’s health.

The issue has remained deeply controversial and bitterly divisive. The legislation in Oklahoma is among the most severe of 500 anti-abortion measures, either passed or proposed, chiefly in Republican-dominated states since a 2007 Supreme Court decision limiting late abortions.

That judgement signalled that the current conservative-dominated court would look more approvingly at states’ efforts to limit the use of abortion, the Daily Telegraph reports.

Oklahoma, with a population of 3.7 million, is already one of the most difficult states in which to get an abortion, with only three doctors willing to perform them. Brad Henry, the state’s Democratic governor, tried to block the bills, but the Republican-dominated legislature raised more than enough votes to override his veto with the help of several Democrats.

Anti-abortion campaigners hailed a victory for their cause. Mary Spaulding Balch, a director at the National Right to Life, said:

‘Ultrasound gives a mother a window to her womb. It helps to prevent her from making a decision she may regret for the rest of her life and it empowers her with the most accurate information about her pregnancy so that she can make a truly informed “choice”.’

A useful article on Medical News Today gives a round-up of commentary from the USA.

Oklahoma forces women to have ultrasound before abortion . Daily Telegraph, 28 April 2010

CNN, NYT, USA Today, Post Opinion Pieces Comment On State Abortion News. Medical News Today, 4 May 2010

USA: Republican lawmaker in ‘porn’ embarrassment

Florida Senator Mike Bennett was spotted viewing topless images of women on his computer during an abortion debate on the Senate floor. 

Sunshine State News reporter Lance Wright spotted video footage of the senator looking at the image of topless women. The footage shows the senator tilting his screen forward before closing down the image, tilting his screen back again.

In the background Senator Dan Gelber’s voice can be heard debating a controversial abortion bill. ‘I’m against this bill,’ Mr Gelber can be heard saying, ‘because it disrespects too many women in the state of Florida.’

When approached by the reporter, Mr Bennett said he was sent the pornographic image in an email from a woman ‘who happens to be a former court administrator’.

‘I was just sitting there, bored as they were debating the abortion bill,’ Mr Bennett said. ‘I opened it up and said holy s***! What’s on my screen? and clicked away from it right away,’ he told the Sunshine State News.

A Senate spokesman said Mr Bennett had thought the email was relating to the abortion bill. He refused to show the Sunshine State News the original email on his computer after consulting with the Senate’s top lawyer. And when asked if he would ever watch porn on the Senate floor, he replied: ‘You’d have to be insane to do that. It all goes through a server. I don’t think anybody would be doing that.’

In an email to the Sunshine State News he wrote: ‘Last Friday, I took a moment to check my personal email account during a quiet minute on the Senate floor. I received several emails from a former city colleague and life-long friend. I had no prior knowledge as to what the emails would contain and when the contents of one was discovered to be less than appropriate, it was promptly closed. I cannot control what individuals may send me and am disappointed that at a time when there are major issues impacting Florida, an insignificant issue such as this receives any attention.’

Gotcha! U.S. lawmaker caught looking at porn on Senate floor. Daily Mail, 6 May 2010

Sen. Mike Bennett Caught Looking at Porn on Senate Floor. Sunshine State News, 3 May 2010

UK: Nadine Dorries talks about abortion time limit

The Conservative MP for Mid-Bedfordshire cites her own ‘20 reasons for 20 weeks’ campaign as a ‘defining issue’ in politics.

In an interview with Bedford Today before the General Election, Nadine Dorries was asked ‘What has been the defining issue of politics over the last five years?’ She replied:

‘For me personally it has been the “20 reasons for 20 weeks” campaign to reduce the upper limit at which abortions can take place.

‘That took two solid years for me and was probably the issue I can look back upon that made the most difference. We informed people and we changed hearts and minds. Although we didn’t change the law we clearly won the argument.’

General Election 2010: Nadine Dorries’ ten tough questions. Bedford Today, 29 April 2010

Also read:

24 reasons for 24 weeks. Tory MP Nadine Dorries has unveiled 20 reasons why the upper time limit for abortion should be lowered to 20 weeks’ gestation. Jennie Bristow, editor of Abortion Review, gives 24 reasons why it should stay as it is. 15 May 2008

USA: Condoms for dual protection: patterns of use with highly effective contraceptive methods

The authors estimated the expected reduction in unplanned pregnancies and abortions if half or all of the women currently using a single highly effective method also used condoms. From Public Health Reports.

The authors note that US women experience high rates of unplanned pregnancy and sexually transmitted infections (STIs), yet they seldom combine condoms with highly effective contraceptives for optimal protection. Because oral contraceptives (OCs) have been the predominant form of highly effective contraception in the US, it is unknown whether condom use is similarly low with increasingly promoted user-independent methods.

The authors used weighted data from the National Survey of Family Growth to assess condom use odds among women relying on OCs vs. user-independent methods (i.e., injectibles, intrauterine devices, and implants). They also estimated the expected reduction in unplanned pregnancies and abortions if half or all of the women currently using a single highly effective method also used condoms.

The results found that across every demographic subgroup based on age, partner status, race/ethnicity, household income, and education, condom use prevalence was lower for women relying on user-independent methods vs. OCs. Multivariable models for adult women also revealed a significant reduction within most demographic subgroups in the odds of condom use among women relying on user-independent methods vs. OCs.

Population estimates suggested that if half of all women using highly effective methods alone also used condoms, approximately 40% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 393,000 unplanned pregnancies and nearly 76,000 abortions. If all highly effective method users also used condoms, approximately 80% of unplanned pregnancies and abortions among these women could be prevented, for an annual reduction of 786,000 unplanned pregnancies and nearly 152,000 abortions.

The authors concluded that adding condoms to other methods should be considered seriously as the first line of defence against unplanned pregnancy and STls. This analysis can serve to target interventions where dual-method promotion is needed most.

Department of Medicine, Emory University School of Medicine, Atlanta, GA 30341-3724, USA.

Condoms for dual protection: patterns of use with highly effective contraceptive methods. Pazol K, Kramer MR, Hogue CJ. Public Health Reports. 2010 Mar-Apr;125(2):208-17.

Poland: ‘When conscience clauses mean women die’

An article by Anna Wilkowska-Landowska on RH Reality Check discusses a disturbing case.

Wilkowska-Landowska writes:

A woman died, because the doctors were afraid she could miscarry and refused to examine her. Whether Poland violated a patient’s right to life or freedom from inhumane and degrading treatment by making her suffer – these are the questions put forward by the European Court of Human Rights in Strasbourg.

When a doctor refuses to carry out a medical service, invoking his or her objections on the ground of conscience, because he or she is afraid of endangering the life of the fetus – in such a case does Poland provide a woman with assistance of another doctor - the Court asks the Polish government.

A 25-year-old pregnant woman from Piła died in 2004 of septic shock before being fully examined by a doctor. Seeking justice in Polish courts proved to be ineffective, so her mother turned to the European Court of Human Rights in Strasbourg and is currently an applicant before the Court represented by two women lawyers, members of the Network of Lawyers of the Federation for Women and Family Planning in collaboration with the Center for Reproductive Rights…

Read on:

Poland: When “Conscience Clauses” Mean Women Die, by Anna Wilkowska-Landowska. RH Reality Check, 3 May 2010

Also read:

Z. v. Poland (European Court of Human Rights). Summary of the case by the Center for Reproductive Rights, 3 April 2009

Statement of facts by the European Court of Human Rights, 19 June 2009

Ethiopia: The estimated incidence of induced abortion, 2008

From International Perspectives on Sexual and Reproductive Health. 

The authors note that unsafe abortion is an important health problem in Ethiopia; however, no national quantitative study of abortion incidence exists. In 2005, the penal code was revised to broaden the indications under which induced abortion is legal. It is important to measure the incidence of legal and illegal induced abortion after the change in the law.

A nationally representative survey of a sample of 347 health facilities that provide postabortion or safe abortion services and a survey of 80 professionals knowledgeable about abortion service provision were conducted in Ethiopia in 2007-2008. Indirect estimation techniques were applied to calculate the incidence of induced abortion. Abortion rates, abortion ratios and unintended pregnancy rates were calculated for the nation and for major regions.

In 2008, an estimated 382,000 induced abortions were performed in Ethiopia, and 52,600 women were treated for complications of such abortions. There were an estimated 103,000 legal procedures in health facilities nationwide--27% of all abortions. Nationally, the annual abortion rate was 23 per 1,000 women aged 15-44, and the abortion ratio was 13 per 100 live births. The abortion rate in Addis Ababa (49 per 1,000 women) was twice the national level. Overall, about 42% of pregnancies were unintended, and the unintended pregnancy rate was 101 per 1,000 women.

The authors concluded that unsafe abortion is still common and exacts a heavy toll on women in Ethiopia. To reduce rates of unplanned pregnancy and unsafe abortion, increased access to high-quality contraceptive care and safe abortion services is needed.

Guttmacher Institute, New York, USA.

The estimated incidence of induced abortion in Ethiopia, 2008. Singh S, Fetters T, Gebreselassie H, Abdella A, Gebrehiwot Y, Kumbi S, Audam S. International Perspectives on Sexual and Reproductive Health. 2010 Mar;36(1):16-25.

USA: Effect of prior caesarean delivery on risk of second-trimester surgical abortion complications

From Obstetrics and Gynecology. 

The study set out to estimate second-trimester surgical abortion complication rates and to estimate the effect of past caesarean delivery on the risk of complications.

Demographic, medical, and operative data were collected prospectively between October 2004 and March 2007 in an academic, urban, US abortion clinic. Complication and intervention rates were calculated. Multivariable logistic regression models were used to evaluate risk factors for a major complication, haemorrhage, cervical laceration, and atony.

The authors included 2,973 second-trimester surgical abortions. Cervical laceration (3.3%), atony (2.6%), and hemorrhage (1.0%) were the most common complications. The rate of major complications (eg, transfusion, disseminated intravascular coagulation, and reoperation) was 1.3%. In multivariable logistic regression modelling, a history of two or more caesarean deliveries was the strongest predictor for having a major complication (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.4-15.8), while additional predictors included gestational age of 20 weeks or more (OR 4.4, 95% CI 2.0-11.4) and insufficient initial cervical preparation requiring further dilation (OR 2.6, 95% CI 1.2-5.4).

The authors concluded that second-trimester surgical abortions were associated with a major complication rate of approximately 1%. A history of two or more caesarean deliveries was associated with a sevenfold increase in odds of major complication and was the strongest independent risk factor for a major complication. LEVEL OF EVIDENCE: III.

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California, USA.

Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Frick AC, Drey EA, Diedrich JT, Steinauer JE. Obstetrics and Gynecology. 2010 Apr;115(4):760-4.

Spain: Mifepristone-misoprostol midtrimester abortion

This study was conducted to explore the effect of gestational age (GA) on the induction-to-abortion interval of mifepristone-misoprostol midtrimester termination of pregnancy (TOP) regimen. From Contraception. 

This study involved a consecutive series of 270 pregnancies between 12.0 and 22.6 weeks that have undergone legal TOP from April 2006 to June 2009. All women received a single oral dose of 200 mg mifepristone and, 36-48 h later, a course of misoprostol (an initial vaginal dose of 800 mcg plus four oral doses of 400 mcg at 3-hourly intervals). Treatment was considered to be a failure if abortion did not occur within 24 h. The impact of GA, parity and maternal age on the induction-to-abortion interval was assessed by means of Cox regression.

Overall, the mean GA at TOP was 18.0 weeks. The mean induction-to-abortion interval was 9.8 h (SD=8.2 h; range=1-50 h), and 246 women (91%) aborted successfully within 24 h. GA at TOP and parity were the only two variables independently associated with the induction-to-abortion interval. The mean induction-to-abortion interval was increased by about 50% in patients undergoing TOP between 20.0 and 22.6 weeks (12.9 h, SD=8.9), as compared with those at 16.0-19.6 weeks (7.8 h, SD=5.9) and 12.0-15.6 weeks (8.2 h, SD=8.3) (p<.001).

The effect of parity on the induction-to-abortion interval was more modest, with a 20% increase in induction-to-abortion interval in nulliparous (10.1 h, SD=9.1), as compared with women with a previous live birth (8.1 h, SD=6.7).

The authors concluded that the mean induction-to-abortion interval increases by 4 h after 20 weeks GA. This information may be relevant for counselling and planning of the procedure.

Department of Maternal-Fetal Medicine, ICGON, Hospital Clínic, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBERER), 08028 Barcelona, Spain.

Mifepristone-misoprostol midtrimester abortion: impact of gestational age on the induction-to-abortion interval. Gómez O, Borrás A, Rabanal A, Palacio M, Carceller A, Coll O, Gratacós E. Contraception. 2010 Feb;81(2):97-101. Epub 2009 Nov 12.

China: The effect of phloroglucinol on pain in first-trimester surgical abortion

The authors concluded that the use of phloroglucinol (4 mL), during first-trimester abortion by suction evacuation under local anesthesia with lidocaine, did not relieve pain, but caused no side effects. From Contraception. 

The authors note that first-trimester surgical abortion is a common procedure. Pain control during this procedure is still an unsolved problem.

In this randomized, double-blind placebo-controlled study, women presenting for first-trimester surgical abortion received intramuscular phloroglucinol (4 mL) or placebo (normal saline, 4 mL). Visual analog scales (VAS) for pain immediately and 30 min after the procedure and side effects of the drug were recorded.

The results found no significant difference between groups in the pain level immediately and 30 min after the procedure; 70.7% of the phloroglucinol group (n=58 cases) and 56.9% of the placebo group (n=58 cases ) reported mild pain; 27.6% and 34.5%, respectively, reported moderate pain; and 1.7% and 8.6%, respectively, reported severe pain. Thirty minutes after the procedure, the median pain score was reduced to 1.3 in both groups. Postoperative side effects were reported, but there was no significant difference between groups for nausea or vomiting and blood pressure.

The authors concluded that the use of this dose of phloroglucinol, during first-trimester abortion by suction evacuation under local anesthesia with lidocaine, did not relieve pain, but caused no side effects.

Women’s Hospital, School of Medicine, Zhejing University, Hangzhou, Zhejiang 310006, PR China.

The effect of phloroglucinol on pain in first-trimester surgical abortion: a double-blind randomized controlled study. Zhuang Y, Zhu X, Huang LL. Contraception. 2010 Feb;81(2):157-60. Epub 2009 Dec 2.

USA: Buccal misoprostol for cervical ripening prior to first trimester abortion

The study’s objective was to assess the necessity of manual dilation of the cervix when buccal misoprostol is used for cervical priming prior to first trimester uterine aspiration procedures. From Contraception. 

The authors note that cervical priming prior to uterine suction evacuation softens the cervix and lessens the force needed for dilation, thereby potentially reducing the probability of procedural complications. The use of buccal misoprostol has been shown to be an adequate cervical primer in second trimester surgical procedures, but its use in first trimester aspiration procedures is not well documented. The study’s objective was to assess the necessity of manual dilation of the cervix when buccal misoprostol is used for cervical priming prior to first trimester uterine aspiration procedures.

This was a retrospective case review of 685 patients who underwent a first trimester aspiration abortion with buccal misoprostol cervical priming from August 24, 2006, to February 23, 2007. All procedures were performed by three experienced physicians.

Adequate dilatation of the cervix was achieved in 44.2% patients. The proportion of patients with adequate dilation decreased with increasing gestational age. Patients requiring additional mechanical dilatation differed significantly between those who were parous (51.0%) and those who were nulliparous (72.4%) (p<.001).

The authors concluded that buccal misoprostol appeared to decrease our need for manual dilation prior to first trimester aspiration abortion. Earlier gestations and parous patients showed less need for manual dilatation than later gestations or nulliparous women. A larger study with a control group is needed to confirm the benefit of the use of buccal misoprostol in first trimester aspiration abortion.

Department of Obstetrics and Gynecology, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA.

Buccal misoprostol for cervical ripening prior to first trimester abortion. Panchal HB, Godfrey EM, Patel A. Contraception. 2010 Feb;81(2):161-4. Epub 2009 Nov 12.

USA: Feasibility of telephone follow-up after medical abortion

This study was conducted to assess the feasibility of using telephone calls combined with high-sensitivity urine pregnancy testing as a primary method of follow-up after medical abortion. From Contraception. 

The authors enrolled 139 women up to 63 days of gestation to receive mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, per their choice. Participants were contacted by phone one week after mifepristone administration and interviewed using standardized questions.

If the subject or clinician thought the pregnancy was not expelled, the subject returned for an ultrasound examination. Otherwise, subjects performed high-sensitivity home urine pregnancy testing 30 days after the mifepristone and were called within 3 days of the test. Those with positive pregnancy tests returned for an ultrasound examination. Those with negative tests required no further follow-up.

Six of the 139 (4.3%, 95% CI 1.6-9.1%) subjects presented prior to Phone Call 1 for an in-person visit. All 133 (100%, 95% CI 97.8-100%) subjects eligible for their first telephone follow-up were contacted. Eight of the 133 (6.1%, 95% CI 2.6-11.5%) women were asked to return for evaluation and all did so (100%, 95% CI 63.1-100%). Eight of the 133 women eligible for the 30 day phone call presented for an interim visit prior to the call.

After 30 days, 116 of the 117 (99.1%, 95% CI 97.5-100%) eligible subjects were contacted. One subject was not reached for the day 30 phone call. Twenty-seven of the 116 (23.3%, 95% CI 15.6-31.0%) subjects had a positive pregnancy test and required follow-up. Two of these subjects (7.4%, 95% CI 1.0-24.2%) did not return for in-person follow-up. Two of the 116 (1.7%, 95% CI 0.2-6.1%) subjects had inconclusive pregnancy tests and were asked to return for follow-up. One of these subjects (50%, 95% CI 1.2-98.7%) did not return.

Complete follow-up was achieved in 135 of the 139 subjects (97.1%, 95% CI 94.3-99.9%). None of the 26 women evaluated for a positive or inconclusive pregnancy test had a gestational sac or continuing pregnancy.

The authors concluded that telephone follow-up combined with urine pregnancy testing after medical abortion is a feasible alternative to routine ultrasonography or serial serum hCG measurements.

University of Pittsburgh School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Pittsburgh, PA 15213, USA.

Feasibility of telephone follow-up after medical abortion. Perriera LK, Reeves MF, Chen BA, Hohmann HL, Hayes J, Creinin MD. Contraception. 2010 Feb;81(2):143-9. Epub 2009 Sep 30.

UK: Head teachers call for improvements to sex education

A survey by the National Association of Headteachers (NAHT) has found that four out of five teachers felt they lacked either the resources or the confidence to teach the subject well, the Independent reports.

Sion Humphreys, of the NAHT‘s education department, said: ‘Teachers have not been adequately trained to deliver it [sex education] and have not had the access to the range of resources they need. This is an urgent need that must be addressed if we are to be able to prepare young people for their future lives.’

Among the suggestions for improvements was the consideration of more resources such as DVDs, as well as the consideration of guest speakers in a bid to alleviate the workload of teachers.

Fewer than one in 10 teachers and only 15 per cent of parents said that they found current teaching materials ‘very useful’. More than a quarter of teachers felt their sex education classes prepared pupils ‘not well’ or ‘not at all well’. More than eight out of 10 parents said sex and relationship education (SRE) should also be delivered at home, but only six out of 10 felt confident about broaching the subject.

David Butler, chief executive of the National Confederation of Parent Teacher Associations (NCPTA), said: ‘We owe it to children to get this right. If SRE lessons aren’t preparing children properly for life as adults, they need to be improved. More needs to be done to ensure teachers are trained in how to deliver sex education. To do this effectively, parents need more information about what children are learning and specific resources to use with their children.’

‘Lack of confidence’ is harming sex education. Independent, 30 April 2010

Italy: Failed abortion story causes ‘outrage’

A 22-week old infant in Rossano, in southern Italy, has been found alive following an unsuccessful abortion.

The mother, pregnant for the first time, had opted for an abortion after prenatal scans revealed that the fetus had a cleft lip and palate, according to reports in the Italian media.

The baby - weighing just 11oz - survived the abortion. He was discovered alive the following day by the hospital chaplain, who had gone to pray beside his body. He found that the baby, wrapped in a sheet with his umbilical cord still attached, was moving and breathing.

The priest raised the alarm and doctors arranged for the infant to be taken to a specialist neo-natal unit at the neighbouring Cosenza hospital, where he died the following morning.

The story has caused outrage in Italy, where many have called for the country’s abortion laws to be changed, the Daily Telegraph reports.

Archbishop Santo Marciano of Rossano-Cariati said the Catholic country should reflect on its attitudes both to the unborn and to the disabled. The prelate said the case should ‘lead civil society to reflect on the tragic character of abortion, in so far as it is the suppression of a human being, and in this case, on the illicit character of the definition “therapeutic”.’

‘In fact, it is not a “cure” but reinforces the eugenic mentality that is spreading, and which not only increases recourse to abortion, but poses serious questions regarding the alleged benefit to the woman’s health and on the natural meaning of maternity,’ he told L’Osservatore Romano, the Vatican newspaper. ‘It also invites us to consider with what ease a person who is seriously malformed and simply undesired is treated inhumanly.’

Bishop Elio Sgreccia, a former senior Vatican official, said the law needed to be clarified to ensure that viable fetuses - those able to survive outside the womb - are protected by law. ‘If the aborted foetus, in a voluntary or accidental way, is alive - also if it is at the limit of survival, at the age limit - the doctor is in the presence of a fetus that, because it is strong or because the dates were not properly calculated, fortunately, is living,’ he said.

Italian police are investigating the case for homicide because infanticide is illegal in Italy. The law means that doctors have had an obligation to try to preserve the life of the child once he had survived the abortion. The Italian government has promised an inquiry.

Since 1978, abortion has been available on demand in Italy in the first three months of pregnancy but is restricted to specific circumstances - such as fetal abnormality - in the second trimester. The government is reportedly considering a review of the working of the laws.

Baby that survived botched abortion was rejected for cleft lip and palate. Daily Telegraph, 29 April 2010

AR update, 30 April 2010

Pregnancy and pregnancy planning in the new parenting culture; Tory party leader calls for review of abortion time limit; No increase in premature baby survival rate; Foreign Office apologises for ‘brainstorm’ memo; New guidance for pharmacists retains ‘conscience clause’; Mexico: child’s pregnancy fuels abortion row, and more…

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This news digest is sent by email to those who have signed up to the Abortion Review Online mailing list. To join the mailing list for free, see here.

A quarterly news digest is provided in the print edition of Abortion Review. You can download the print edition for free here.

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- 1. EVENT: PREGNANCY AND PREGNANCY PLANNING IN THE NEW PARENTING CULTURE

This two day seminar in June, organised by Parenting Culture Studies and the Kent Centre for Law Gender and Sexuality, and supported by BPAS and the Economic and Social Research Council, will discuss the relationship between reproductive autonomy and a culture of ‘intensive parenting’.

Speakers include:

-- KRISTIN LUKER, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology, University of California: ‘Abortion and the politics of motherhood revisited’

-- RACHEL JONES, Senior Research Associate, Guttmacher Institute, New York: ‘Abortion decision making in a culture of “intensive motherhood“‘

-- DANIELLE BASSETT, Charlotte Ellertson Social Science Postdoctoral Fellow, Ibis Reproductive Health, Cambridge, MA: ‘Pregnancy after abortion: women’s experiences of a stigmatised reproductive career’

Places are limited, so early booking is advised. For details, see here. 

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Also read:

- 2. COMMENTARY: EXTENDING PARENTING BACKWARDS

Jennie Bristow, editor of Abortion Review, explores some of the new limitations placed on women’s autonomy by modern parenting culture.

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ALSO NEW ON ABORTION REVIEW

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- 3. UK: TORY PARTY LEADER CALLS FOR REVIEW OF ABORTION TIME LIMIT

In an interview with the Catholic Herald, David Cameron discussed conscience issues such as abortion and euthanasia.

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- 4. UK: NO INCREASE IN PREMATURE BABY SURVIVAL RATE

Babies born before 24 weeks are spending longer periods in intensive care but their overall survival rates have not improved, a study has found.

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- 5. COMMENTARY: IT’S TIME TO MOVE BEYOND ROE VS WADE

Stuart Derbyshire argues that for the past 30 years, it has been the Supreme Court, and not broader US society, that has made the necessary decisions about abortion.

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- 6. COMMENTARY: FAMILY PLANNING SHOULD MEAN CHOICE, NOT CONTROL

Jennie Bristow reports on the ‘morally uncomfortable’ questions raised by a conference examining the alleged connection between population dynamics, reproductive health and rights, and climate change.

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- 7. MEXICO: CHILD’S PREGNANCY FUELS ABORTION ROW

A pregnant 10-year-old, allegedly raped by her stepfather, has become the latest lightning rod in the country’s heated abortion debate.

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- 8. INDIA: DOCTOR ARRESTED OVER ‘DUMPED FETUSES’

Police in the western Indian state of Gujarat have arrested a doctor after 14 human fetuses were found in rubbish, BBC News Online reports.

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- 9. UK: FOREIGN OFFICE APOLOGISES FOR ‘BRAINSTORM’ MEMO

The Pope’s visit to Britain will not be affected by a leaked memo which appeared to mock the Catholic Church, the Vatican has said.

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- 10. UK: CAMPAIGN TO ARREST THE POPE

Leading atheist Richard Dawkins has backed a campaign to have the Pope arrested for ‘crimes against humanity’ when he visits the UK later this year.

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- 11. UK: MORE GP SURGERIES INTENDING TO PROVIDE EARLY MEDICAL ABORTION

Data shows that four health trusts in England have requested licences to carry out EMA in GP surgeries.

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- 12. UK: NEW GUIDANCE FOR PHARMACISTS RETAINS ‘CONSCIENCE CLAUSE’

Pharmacists across the UK have been told they can continue to refuse to prescribe items that might clash with their personal religious beliefs.

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- 13. UK: FEWER RESTRICTIONS ON TV CONDOM ADS

Advertising regulators have unveiled new rules about condom advertising and pregnancy advice services.

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- 14. UK: SEX EDUCATION REFORMS SHELVED

The Secretary of State for Children, Schools and Families has been forced to drop key reforms to sex education in schools.

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MORE ABORTION NEWS

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For news updates from the UK, see here.

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For news updates from around the world, see here.

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MEDICAL UPDATE

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For updates from the medical press, see here.

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Israel: Nulliparity, fertility treatments and twins

The study set out to evaluate the risk that nulliparity poses to the outcome of twin pregnancies, an issue that gained importance due to the rise of twin gestations following assisted reproduction interventions. From Fertility and Sterility. 

This was a prospective cohort study. Between January 1, 2004, and January 7, 2008, the authors prospectively enrolled all pregnancies achieved by assisted reproduction techniques and including ovulation induction, which successfully completed the first trimester. Pregnancies achieved by egg donation were excluded. The main outcome measures were second trimester abortion and severe prematurity (delivery before 32 weeks) rates and the number of live births.

Two-hundred-forty-three twin pregnancies were available for evaluation. Second trimester miscarriage rate was 9.3% in nulliparas and 2.4% in multiparas (P=0.061). Severe prematurity rate was 15.1% in nulliparas compared with 2.5% in multiparas (P=0.003). Better outcome of multiparas was also demonstrated by the calculated chance of taking home at least one baby: 97.6% for multiparas compared with 89.2% in nulliparas (P=0.024).

The authors concluded that nulliparity is a risk factor for a poor outcome in twin pregnancies achieved by fertility treatments and is associated with an increased risk for severe prematurity and possibly late abortions. This information should be relayed to the patients undergoing fertility treatments and is a consideration regarding the number of fetuses in relation to parity.

Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Department of Obstetrics and Gynecology, Meir Medical Center, Kfar-Saba, Israel.

Nulliparity, fertility treatments and twins: a time for rethinking. Berkovitz A, Hershko-Klement A, Fejgin M. Fertility and Sterility. 2010 Apr;93(6):1957-60. Epub 2009 Feb 27.

Event: Pregnancy and pregnancy planning in the new parenting culture

A two day seminar in June, organised by Parenting Culture Studies and the Kent Centre for Law Gender and Sexuality, and supported by BPAS and the Economic and Social Research Council. 

This event, held at the University of Kent in the UK, will explore the idea that ‘parenting’ is extending backwards as the imperatives of parenting culture come to shape pregnancy and even the time pre-conception.

The intellectual backdrop is a body of scholarship concerned with the content and effects of contemporary parenting culture. This work shows how childrearing is mediated through a cultural narrative that provides mothers and, increasingly, fathers with rules – sometimes ambiguous – about how to realise their roles as parents.

It shows how childrearing has intensified, expanding to encompass a range of activities that were not previously seen as an obligatory dimension of this task. It has also indicated how the expansion of the childrearing role has encouraged the belief that ‘parenting’ is a problematic sphere of social life, requiring much attention from policy makers.

The agenda for this seminar is grounded in the observation that the imperatives of this parenting culture have begun to extend backwards: ideas about motherhood (and fatherhood) and the responsibilities entailed have begun to influence concerns about, and practices surrounding, the time before a child is born. Pregnancy and even pre-pregnancy have become sites for ‘parent training’.

Over two days, international scholars from a range of disciplines will discuss and evaluate with an academic, professional and lay audience the ways in which such extension of ‘parenting’ backwards is becoming apparent, for example:

-- In the official and unofficial advice given to mothers and, increasingly, fathers about the health risks they should consider when planning a pregnancy and after conception;

-- In the ways regulations about reproductive medicine reflect not only medical innovation but also new ideas about parenting and parenthood;

-- In innovations in reproductive health policy and in the decisions made by women about childbearing and abortion.

Speakers and papers include:

-- Professor Kristin Luker, Elizabeth Josselyn Boalt Professor of Law and Professor of Sociology, University of California: ‘Abortion and the politics of motherhood revisited’

-- Rachel Jones, Senior Research Associate, Guttmacher Institute, New York: ‘Abortion decision making in a culture of “intensive motherhood"’

-- Danielle Bessett, Ph.D., Charlotte Ellertson Social Science Postdoctoral Fellow, Ibis Reproductive Health, Cambridge, MA: ‘Pregnancy after Abortion: women’s experiences of a stigmatized reproductive career’

-- Evelyn Mahon, Senior Lecturer in Sociology at the School of Social Work and Social Policy, Trinity College Dublin: ‘Is there ever a good time to have a child?’

-- Elizabeth Mitchell Armstrong, Associate Professor of Sociology and Public Affairs, Princeton University: ‘Do happier pregnancies make healthier babies? Stress and the medicalization of maternal emotion’

-- Cynthia Daniels, Professor of Political Science, Rutgers University: ‘Policing pregnancy: The politics of fetal risks’

-- What’s wrong with advocating alcohol abstinence to pregnant women? Perspectives from the US and Britain. Janet Golden, Professor of History, Rutgers University; Pam Lowe, Lecturer in Sociology, Aston University.

-- Martin Richards, Emeritus Professor of Family Research, Cambridge University: ‘Present practice and future developments in the culture of choice’

-- Julie McCandless, lecturer in law, Oxford Brookes University: ‘What is “supportive parenting”? The new ‘Welfare of the Child’

Download the full programme here.

Date: Tuesday 22 and Wednesday 23 June 2010

Venue: University of Kent, Canterbury, UK

Booking: Early booking is advised as places are limited. Tickets £120 two days / £80 one day (employed); £25 (students and unwaged). Email at the University of Kent.

Further information: Contact the event organiser, Jan Macvarish, at the University of Kent. Email: .

Also read:

Commentary: Extending parenting backwards, by Jennie Bristow. Abortion Review, 29 April 2010

Commentary: Extending parenting backwards

Jennie Bristow, editor of Abortion Review, explores some of the new limitations placed on women’s autonomy by a culture of ‘intensive parenting’. 

In June 2010, the University of Kent will host a two-day seminar, supported by BPAS, on the theme of ‘pregnancy and pregnancy planning in the new parenting culture’. The seminar takes as its starting point new developments in modern parenting culture, in which themes of ‘intensive parenting’ and ‘responsible parenthood’ have come to shape the direction of social policy. International scholars from a range of disciplines will discuss these themes with an academic, professional and lay audience, focusing on their relationship to women’s autonomy and reproductive decision-making.

Policy over recent decades has become increasingly interested in, and interventionist on, parents’ activities in relation to their children’s health, education and behaviour, situating ‘parenting’ as a key site of political concern. It is not now unusual to see policy measures directed specifically at indicating what foods parents should feed their children, or the extent of their involvement in their child’s homework. While many see such developments as contributing positively to a model of responsible parenthood, by giving parents official advice and support in making the best decisions regarding everyday family life, others have warned that putting parenting practices under the spotlight in this way can have some negative consequences in terms of parental autonomy and confidence in what have historically been considered private matters of child-rearing.

It has also been argued that, in an era marked by an attachment to ‘evidence-based policy’, the evidence base for promoting ‘one method’ of feeding, educating or disciplining children is rather weak; and that children’s health and development is the result of a wider range of factors than can be determined simply by the diet their parents feed them, or the amount of time spent reading to them in the evening.

The University of Kent seminar will draw upon this discussion to examine how the imperatives of this new parenting culture have begun to ‘extend backwards’ into pregnancy and pre-pregnancy, with important consequences for women’s reproductive autonomy. The desire to produce the ‘optimal child’, promoted by policy-makers but increasingly shared by women themselves, has led to an increasingly stark distinction between acceptable and non-acceptable behaviour in pregnant women. Smoking, drinking alcohol, eating certain types of food and taking any kind of medication have become areas of intense concern and anxiety.

The fear is that a pregnant woman might harm her fetus by ingesting the wrong kind of substance, and the conclusion often drawn is that she should therefore err on the side of caution by avoiding any ‘risky’ behaviour during pregnancy, and avoiding becoming pregnant until she has changed her lifestyle in the appropriate ways.

It is known that certain substances and medications can have a negative impact on fetal development, or even cause abnormalities, and it is sensible to take this knowledge into account. Of interest to the conference, however, is the way that even substances or behaviours that have not been proven to cause harm are now tagged as things that the pregnant woman should avoid. One example of this is the 2007 decision, by the Department of Health and the National Institute for Clinical Excellence (NICE), to advise pregnant women and those who may be thinking of becoming pregnant to avoid alcohol completely. This new advice was not based on any new evidence about the harm that alcohol might cause the fetus: there is no evidence that moderate drinking during pregnancy has any effect, and as some important American studies have indicated, the evidence that even heavy drinking harms the fetus is far less clear-cut than is generally presumed.

The justification given for bringing in new official advice about abstaining from alcohol during pregnancy was not based on evidence, but on the presumed need for behavioural change. Encouraging women to change their lifestyle habits (in particular, their drinking behaviour) is now accepted as a necessary precondition for responsible motherhood. This is why the advice extends to women who are merely thinking of becoming pregnant: the effect of alcohol upon the fetus cannot be significant here, as there is no fetus; the issue is one of adopting appropriate maternal attitudes and behaviour.

The effect of these developments upon women’s reproductive autonomy is significant. While antenatal care has always exercised a degree of control over women’s behaviour, both the expansion of the maternal behaviours seen as problematic and the extension of these concerns to women before they become pregnant, indicates a tendency towards the increasing regulation of women’s private choices.

Seminar participants will discuss how the phenomenon of ‘extending parenting backwards’ can also impact negatively on women’s reproductive choices regarding contraception and abortion. A woman’s ability to decide, for herself, the circumstances under which she wants to have a child, and to avoid or terminate a pregnancy if those circumstances are not favourable, has been one of the great gains of modern history. But in circumstances where there is a high cultural expectation of the ‘perfect pregnant woman’ as a necessary precondition for creating the optimal child, and where this expectation is often shared by women before they become pregnant, women might find their personal fertility decisions unduly shaped by wider cultural concerns. 

For example, the woman who decides to terminate an unintended pregnancy because she was out drinking with her friends before discovering that she was pregnant, or the woman who worries that her use of hair dye and prescription drugs may have adversely affected the developing fetus, might be seen to be making the responsible choice by having an abortion rather than carrying the pregnancy to term.

However, when the actual scientific evidence about a causal link between the woman’s behaviour and the fetus is weak, and where her choice to terminate the pregnancy has been informed more by anxiety and pressure about the potential negative consequences of her behaviour than by the question of whether or not she wants to have a baby right now, there is a need to address the extent to which the new parenting culture places restrictions on women’s decision-making.

For more details about the seminar, see the Parenting Culture Studies website.

Tickets cost £120 two days / £80 one day (employed); £25 (students and unwaged). Email .

UK: Foreign Office apologises for ‘brainstorm’ memo

The Pope’s visit to Britain will not be affected by a leaked memo which appeared to mock the Catholic Church, the Vatican has said.

The Foreign Office has apologised over the paper resulting from a ‘brainstorm’ that said the Pope could bless a gay marriage or open an abortion clinic, BBC News Online reports.

UK newspaper reports have quoted Vatican sources as saying the September visit could now be in doubt.

But Vatican spokesman Federico Lombardi said: ‘For us the case is closed’. Noting the Foreign Office’s apology, Fr Lombardi told the ANSA news agency the incident would have ‘absolutely’ no impact on the Pope’s 16 to 19 September visit.

The Foreign Office has stressed the internal memo by a junior civil servant containing ‘naive and disrespectful’ ideas for marking the visit did not reflect its views. Details of the document, which also suggested the visit could be marked by special ‘Benedict’ condoms, emerged after it was obtained by the Sunday Telegraph.

It prompted the UK’s ambassador to the Vatican, Francis Campbell, to meet senior officials of the Holy See to express regret on behalf of the government.

The junior civil servant responsible for setting up the brainstorming and circulating its results said in a cover note: ‘Please protect; these should not be shared externally. The ‘ideal visit’ paper in particular was the product of a brainstorm which took into account even the most far-fetched of ideas’, BBC News Online reports.  The civil servant had since been put on other duties, the Foreign Office said.

Peter Forster, the bishop of Chester, argued that the memo is symptomatic of a greater problem between religion and the secular government.

‘I think that Christianity has been so much a part of the furniture of our society that it tends to be neglected and taken for granted,’ Dr Forster told BBC Radio 4’s Today programme. ‘There’s a “familiarity breeding contempt” in some circles of society about our Christian heritage which leads to the distasteful events we had yesterday with that memo.’

The ideas were attached as one of three ‘background documents’ to a memo dated 5 March 2010 inviting officials in Whitehall and Downing Street to attend a meeting to discuss themes for the papal visit. It suggested Benedict XVI could show his hard line on the sensitive issue of child abuse allegations against Roman Catholic priests by ‘sacking dodgy bishops’ and launching a helpline for abused children. The document went on to propose the Pope could apologise for the Spanish Armada or sing a song with the Queen for charity.

Pope Benedict XVI’s visit is expected to take in Birmingham, as part of the planned beatification of Cardinal John Newman, and Scotland. It will be the first papal visit in the UK since John Paul II’s visit in 1982.

Leaked FCO memo ‘will not affect Pope visit’. BBC News Online, 26 April 2010.

UK: A comparison of transabdominal and transvaginal ultrasonography in early medical abortion

The authors sought to establish the accuracy of abdominal ultrasonography in determining gestational age and identifying the presence of a gestational sac and embryonic pole before and after medical abortion. From Contraception. 

This study included all 120 women enrolled in a study of simultaneous oral mifepristone and buccal misoprostol for abortion through 63 days’ gestation. Vaginal and abdominal ultrasound examinations were performed before and 24 h after medication administration. Visualisation of a gestational sac and embryonic pole and presence or absence of cardiac activity were recorded. Sensitivity and specificity were calculated with the results from vaginal ultrasonography as the gold standard. The effect of body mass index (BMI) on ultrasound findings was also assessed.

Before treatment, the sensitivities of abdominal ultrasonography were 100% (95% CI 97-100) and 68% (95% CI 58-77) for presence of a gestational sac and an embryonic pole, respectively. Overall, abdominal imaging underestimated mean gestational age by 1.6 days (95% CI 1.0-2.2). After treatment, abdominal ultrasonography missed three of 34 retained gestational sacs (sensitivity 91%, 95% CI 76-98%). Fourteen women had gestational cardiac activity by vaginal ultrasound at follow-up. Abdominal imaging identified the gestational sac in all cases, but cardiac motion was only visible in 10 (71%, 95% CI 42-92%). For every 10-point increase in BMI, the odds ratio for missing an embryonic pole at baseline was 2.8 (95% CI 1.5-5.0).

The authors concluded that abdominal ultrasonography is sensitive for diagnosing the presence or absence of a gestational sac, but less sensitive at detecting an embryonic pole. This may lead to a small underestimation of gestational age and missing a continuing pregnancy at follow-up when one exists.

bpas, Stratford Upon Avon, UK.

A comparison of transabdominal and transvaginal ultrasonography for determination of gestational age and clinical outcomes in women undergoing early medical abortion. Lohr PA, Reeves MF, Creinin MD. Contraception. 2010 Mar;81(3):240-4. Epub 2009 Nov 14.

‘It’s time to move beyond Roe vs Wade’

An interesting commentary by Stuart Derbyshire argues that for the past 30 years, it has been the Supreme Court, and not broader US society, that has made the necessary decisions about abortion.

Writing on the website spiked, Derbyshire argues:

The Republican governor of Nebraska, Dave Heineman, signed a bill on 13 April to ban abortions from 20 weeks’ gestation in his state. The bill is entitled the Pain-Capable Unborn Child Protection Act and will ban abortion on the grounds that the fetus can feel pain from 20 weeks onwards (1). The bill is scheduled to come into effect on 15 October, but will almost certainly face several legal challenges before then. Nevertheless, if successfully passed, it will be the first time US abortion has been restricted on any grounds except viability since the historic decision by the Supreme Court in Roe vs Wade in 1973.

US legislative interest in the possibility of fetal pain has increased since 2003 when the Bush administration successfully passed the Partial-Birth Abortion Ban Act (HR 760). This act was immediately challenged in New York, California and Nebraska on the grounds that women are constitutionally required to have access to abortion to preserve their own health. Those challenges were successful, and HR 760 was overturned, but the possibility of fetal pain was raised as evidence in each state by the expert witness Dr Kanwaljeet (Sunny) Anand. Judge Casey, who oversaw proceedings in New York, pointedly remarked in his summing-up that this evidence was never challenged.

Anand’s testimony spawned the 2005 Unborn Child Pain Awareness Act, which Congress debated in 2006. The bill secured a majority, but failed to obtain the two-thirds majority necessary to pass as a law. State efforts, however, have been more successful. At least 25 US states have deliberated on fetal pain legislation and at least eight (Alaska, Arkansas, Georgia, Oklahoma, South Dakota, South Louisiana, Texas and Wisconsin) now have legislation requiring that women seeking abortions be informed of the possibility of fetal pain. If successful, the Nebraska legislation will add to this growing trend to use fetal pain to restrict access to abortion. The Nebraska legislation will also extend that trend by becoming the first law directly to prevent a requested abortion on the grounds of fetal pain.

The proposed Nebraska law also has its origins in the murder of Dr George R Tiller. Tiller provided late-term abortions in Wichita, Kansas until abortion opponent Scott Roeder shot and killed him on 31 May 2009. Tiller’s clinic subsequently closed, but LeRoy Carhart then stated that he would perform some late term abortions at his clinic in Bellevue, Nebraska.

Dr Carhart has been a long-time thorn in the side of abortion opponents in Nebraska. Carhart, for example, led the team of physicians that successfully challenged the Nebraska state in the Partial-Birth Abortion Ban Act trials. Carhart will be the only practitioner in Nebraska affected by the new bill after October and he may mount a legal challenge to prevent his work being curtailed.

A challenge to Roe vs Wade

The Nebraska Bill will prevent abortions before viability and so it is a direct challenge to the constitutional principles established by Roe vs Wade. Consequently, any legal process could eventually end at the Supreme Court. The possibility of using fetal pain to restrict abortion nationally will then rest on the decision of the nine Supreme Court judges. Five of those judges (Kennedy, Roberts, Alito, Thomas and Scalia) previously voted for the Partial-Birth Abortion Ban Act when that act reached the Supreme Court in 2007. It seems likely that those five judges will at least be open to supporting Nebraska. If supportive of Nebraska, those five votes would provide the majority necessary to overturn the constitutional principles founded in Roe vs Wade and potentially end a relatively liberal era in US abortion access.

Will a legal challenge succeed?

A legal challenge to Nebraska is likely to focus on two major points. The first is that states are typically not permitted to legislate in the face of medical uncertainty. And whether the fetus feels pain is highly uncertain. Mark Rosen, senior author of a 2005 review of fetal pain published in the Journal of the American Medical Association, sent a letter to the Nebraska Legislature on 30 March documenting the medical uncertainty regarding fetal pain.

In section 3 of the Nebraska Bill, the legislature makes the following points:

1) At least by 20 weeks after fertilisation there is substantial evidence that an unborn child has the physical structures necessary to experience pain;
2) There is substantial evidence that, by 20 weeks after fertilisation, unborn children seek to evade certain stimuli in a manner which in an infant or an adult would be interpreted as a response to pain;
3) Anaesthesia is routinely administered to unborn children who have developed 20 weeks or more past fertilisation who undergo prenatal surgery;
4) Even before 20 weeks after fertilisation, unborn children have been observed to exhibit hormonal stress responses to painful stimuli - and such responses were reduced when pain medication was administered directly to such unborn children;
5) It is the purpose of the State of Nebraska to assert a compelling state interest in protecting the lives of unborn children from the stage at which substantial medical evidence indicates that they are capable of feeling pain.

However, in his letter to the Nebraska Legislature, Mark Rosen noted, correctly, that at 20 weeks’ gestation there is broad agreement that the physical structures necessary for pain are not fully developed or functional. Any responses to noxious stimuli at 20 weeks are akin to reflexive responses that do not involve conscious awareness. Furthermore, Rosen said, again correctly, that the use of anaesthesia during prenatal operations on fetuses is intended only to facilitate the operative procedure, by, for example, ensuring stillness, and to promote future good health - it is not about preventing current pain. A hormonal stress response cannot be equated with a painful experience and there is, contrary to the assertions of the bill, only speculation and conjecture regarding the possibility of fetal pain.

I am sympathetic to Rosen’s view and have written extensively to oppose the idea of fetal pain. But the argument is highly technical and relies on an acceptance of pain as a conscious state involving the higher regions of the brain. The court might legitimately argue that pain is a simpler state of being and while the fetus might not experience a ‘pain’ equivalent to the pain experienced by conscious adults and infants, ‘fetal pain’ might still matter. The fetus certainly reacts when a noxious event happens and that reaction might be enough for the court to use the term pain and reject the claim of ‘medical uncertainty’. Professor Anand has been influential in past court debates regarding fetal pain and he is likely to play an important role again should the issue reach court.

The second major point of any legal challenge is likely to focus on the constitutional requirements set in place by the Roe v Wade ruling. This ruling declared most state laws, which then prohibited access to abortion, to be unconstitutional. The Supreme Court’s decision prevented all legislative interference in abortion during the first trimester, and allowed restrictions during the second trimester only to protect the health of the woman. In the third trimester, after viability, a state could create legal barriers to abortion, provided it made exceptions to preserve the life and health of the woman seeking abortion.

The current Nebraska bill includes an exception to protect the health of the woman. An abortion can proceed after 20 weeks if, ‘in reasonable medical judgment, [the pregnant woman] has a condition which so complicates her medical condition as to necessitate the abortion of her pregnancy to avert her death or to avert serious risk of substantial and irreversible physical impairment of a major bodily function’. If it is accepted that the Nebraska bill includes sufficient health protections, then any constitutional challenge will rely on the argument that the bill imposes an undue burden on a woman’s right to choose an abortion or violates a woman’s right to equal protection from the law or fails to serve any legitimate state interest. The success or failure of those arguments will boil down to whether a majority of the nine Supreme Court judges wish to uphold the constitutional arrangement provided by Roe vs Wade. They may not think that constitutional arrangement to be necessary.

Is a legal challenge the right way to go?

Tactically, it is reasonable to fight the Nebraska legislation through the courts. But it should be understood that it is a narrow means of protecting access to abortion in the United States and there is the real possibility of failure. It is inevitable that one day a majority of Supreme Court judges will turn against the precedent set in Roe vs Wade if the opportunity arises.

Perhaps now is the time for the pro-choice lobby to recognise that Roe vs Wade was a mixed blessing. For the past 30 years, it has been the Supreme Court, and not broader society, that has made the necessary decisions about abortion. Justice Blackmun’s majority opinion in Roe focused on abortion as a privacy right (the ability of patients and doctors to pursue clinical decisions without fear of interference from the state) and the right of clinicians to practice their profession. In contrast, the rights of women to control their bodies and their destinies did not feature in the 1973 opinion. Roe effectively took the power to decide about abortion away from society and gave that power to the Supreme Court. Thus began more than 30 years of legal wrangling and posturing over abortion that has increasingly pushed everyone but lawyers and judges to the side.

In an important sense, the battle for autonomy over fertility was lost in 1973 rather than won because the battle shifted away from women’s autonomy to decide their life course as equal citizens and towards influencing nine Supreme Court judges. Women need access to abortion to have control over their own destinies rather than having their destiny dictated by a biological accident. Whether the fetus feels pain or is viable are both besides the point – at every gestational point the fetus is fully integrated into the woman’s physiology with no independent existence, and nobody, including the Supreme Court, should be able to force someone to do something with their body that they don’t want to do.

The possibility of Roe vs Wade being overturned is of considerable concern. The consequences would be negative, especially for poor women living in more conservative states. But a potentially negative situation might be turned more positive if those with pro-choice sentiments start to recognise the limitations of abortion politics that Roe created. Women’s access to abortion in the US is under constant threat of curtailment for as long as that access depends on the opinion of the Supreme Court. Defending the legacy of Roe is thus limited and it is overly defensive to suggest that an argument for improved access to abortion cannot be won in modern America. Anyone who values women’s autonomy as independent citizens should challenge the unwarranted control the Supreme Court has over abortion.

Stuart Derbyshire is senior lecturer in psychology at the University of Birmingham, England. This article first appeared on spiked.

WHO publishes new Emergency Contraception safety factsheet

The World Health Organisation’s factsheet comes in response to in response to media coverage in 2009. 

The statement uses a thorough literature review and a review of the extensive review by experts to draw its conclusions that:

‘A careful review of the evidence shows that levonorgestrel-alone emergency contraceptive pills are very safe. They do not cause abortion or harm future fertility. Side-effects are uncommon and generally mild.’

Anna Glasier and Elizabeth Westley have written a commentary to accompany the statement, for the April edition of the WHO Bulletin.

Fact sheet: Safety of levonorgestrel-alone emergency contraceptive pills. World Health Organization, April 2010. [pdf]

Emergency contraception: dispelling the myths and misperceptions. Elizabeth Westley and Anna Glasier. Bulletin of the World Health Organization 2010;88:243-243. doi: 10.2471/BLT.10.077446. Correspondence to .

UK: No increase in premature baby survival rate

Babies born before 24 weeks are spending longer periods in intensive care but their overall survival rates have not improved, a study has found.

Newcastle doctors say while more babies over 24 weeks do now live, the longer-term rates for infants just a week younger are static, BBC News Online reports. About 20% of such babies survive, but those who do usually have disabilities.

The study, published in Archives of Disease in Childhood, looked at 230 babies born at 22 and 23 weeks. Over the course of 15 years, the length and intensity of treatment appeared to increase: the average survival time of those babies who ultimately died rose from 11 hours in 1993 to nearly four days by 2007.

But despite more active intervention being documented in the last five years of the study, in which 60% of the babies born were actively resuscitated, the longer-term survival rates did not appear to increase.

The findings are in keeping with those of the major Epicure study, which showed that while survival rates for babies born at 24 and 25 weeks have improved over the last ten years those for younger infants have not, as their organs are simply not sufficiently developed.

Guidelines have been drawn up which recommend no resuscitation be carried out at 22 weeks, and only at the parents’ request at 23 weeks following a full discussion about the possible outcomes.

‘We know anecdotally that more parents are asking for resuscitation and more doctors are offering it. We are not making a value judgement about this, and for many this may be the right thing to do - even if it only brings an extra three days of life,’ says Dr Nicholas Embleton, a neonatologist at Newcastle’s Royal Victoria Infirmary, who led the research. ‘Cost should not be an issue when making these decisions, but we do need to think about what these babies may go through, the increasing interventions, in the hope that they may survive.’

Discussion about the survival rates of the most premature babies also takes place against the backdrop of the debate about abortion. There have been attempts to reduce the current 24 week limit for terminations to 22 weeks on the grounds of viability.

‘It is really because of the abortion debate that we have got so fixated by weeks when it comes to premature babies, and the shame about this study is that it didn’t move beyond that,’ says John Wyatt, professor of Ethics & Perinatology at University College London. ‘What we really need to start looking at is weight, sex, whether it is singleton pregnancy and whether steroids have been given. A girl is much more likely to survive than a boy, for instance, and the heavier the better. If we can give parents an individualised chance of survival, we really would be getting somewhere.’

Early baby survival rate ‘static’. BBC News Online, 21 April 2010

Survival in infants live born at less than 24 weeks’ gestation: the hidden morbidity of non-survivors. By Ravi Swamy, Sitikant Mohapatra, Mary Bythell, Nicholas D Embleton. Archives of Disease in Childhood - Fetal and Neonatal Edition. doi:10.1136/adc.2009.171629

WHO: Cervical preparation for first trimester surgical abortion

This review set out to determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred. From Cochrane Database of Systematic Reviews.

This review notes that preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy.

The study set out to determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred. The authors searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, they hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.

The selection criteria were randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review.

Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data.

The main results found that, when compared to placebo, misoprostol (400-600 microg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F(2alpha) (2.5 mg administered intracervically) demonstrated larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion.

Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.When misoprostol (600 microg oral or 800 microg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects.

Compared to day-prior laminaria tents, 200 or 400 microg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E(2) andF(2alpha)) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women’s satisfaction with cervical preparatory techniques.

The authors concluded that modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion.

Mifepristone 200 mg, osmotic dilators and misoprostol, 400microg administered either vaginally or sublingually, are the most effective methods of cervical preparation.

Department of Reproductive Health and Research, World Health Organization, 20 Rue Appia, Geneva 27, Switzerland, CH-1211.

Cervical preparation for first trimester surgical abortion. Kapp N, Lohr PA, Ngo TD, Hayes JL. Cochrane Database of Systematic Reviews. 2010 Feb 17;2:CD007207.

Comment in: Obstetrics and Gynecology. 2010 May;115(5):1075-6.

UK: Claims about survival of low birth weight babies made to call for lower abortion time limit

The number of babies born weighing only 2lbs has more than doubled in just two years, the Daily Mail reports.

Health service figures show that in 2008/09, some 3,836 children weighing under 2lbs3oz (1kg) were born in England and Wales. That is a 115 per cent rise on 2006/07.

The statistics do not reveal at what stage the babies were born. But a child weighing under 2lbs 3oz is likely to have been born at least three months early, claims the Daily Mail, ‘re-igniting the emotive debate over the abortion time limit’.

A spokesman for the ProLife Alliance said: ‘These statistics are yet more proof that more and more babies are being born very prematurely and surviving. The evidence is increasingly showing that the 24-week limit allows the abortion of babies capable of surviving. The momentum for lowering the limit is increasing and opposition can only be described as ideological.’

Nadine Dorries, a Tory MP and former nurse, led the failed attempt in 2008 to reduce the 24-week time limit for abortion. She said: ‘The push to lower the limit made everyone aware what happens during fetal development and when. This information reinforces the need to lower the limit as a matter of urgency.’

Doctors said the rise in the number of premature babies was due to a vast improvement in neonatal equipment. There was also a more general rise in women going into labour prematurely.

Consultant Patrick O’Brien, spokesman for the Royal College of Obstetricians and Gynaecologists, believes the figures have been gradually rising for ten to 15 years. ‘We are more willing to step in and deliver a small baby early than we would have been ten years ago because the baby has a much greater chance of survival,’ he said. ‘There have been major leaps in neo-natal care.’

But he cautioned that many will be far from healthy, with half of those born at 24 weeks suffering from cerebral palsy. Other complications include kidney and bowel problems, dyslexia and clumsiness. The annual care bill is estimated at £125million.

Ann Furedi, chief executive of BPAS, said: ‘Over recent decades there has been an overall rise in the numbers of babies born, so we can also expect that, regrettably, some of this larger cohort of babies born will be born prematurely. However, very sadly for the parents of prem babies, a greater number of prematurely-born babies is not the same thing as an increased likelihood of fetal survival.

‘Fetal survival is closely linked with gestation, which these figures give no information on, rather than being dictated just by birthweight. Neonatologists tell us that the proper development of premature babies’ lungs is crucial in their chances of survival beyond the delivery room, for example. Studies show that unfortunately, the survival chances for babies born under 24 weeks’ gestation have not improved, because at this stage babies are generally very physically under-developed and are less able to respond to specialist care. This is despite great advances in hospital care for babies born at 25 weeks and above.

‘The 24 week time limit for abortion was examined and endorsed just recently. Politicians and policy makers looked at the reasons why women need access to later terminations and accepted that these often are in circumstances where it would be nothing short of brutal to deny them treatment. Very few women need abortions after 20 weeks, but those that do need support and understanding.’

Writing in the Mirror, Miriam Stoppard argued:

‘To say life is viable at this stage is misleading and would give false hope to parents of extremely premature babies. But, that aside, surely the main point should be a woman’s right to choose and not whether a baby might survive with medical intervention?’

Calls to reduce abortion limit as number of 2lb survivors soars. Daily Mail, 20 April 2010

We mustn’t meddle with the abortion time limit, by Miriam Stoppard. Mirror, 22 April 2010.

Also read:

UK abortion law section, Abortion Review

‘Will Christians swing the 2010 UK election?’

An article by Justin Parkinson on BBC News Online asks whether political candidates may be more likely to discuss their religious beliefs than is usually the case in British elections. 

Parkinson writes:

Tony Blair’s spokesman Alastair Campbell famously once said the prime minister didn’t ‘do God’ when talking to the media. Religious pronouncements were kept to a minimum, for fear of risking the broad political support for the New Labour project.

Mr Campbell’s simple words illustrate how Christianity is generally treated at Westminster. Explicit mention of religion is seen as ‘un-British’, a bit ‘American’ and a ‘turn-off’ to the electorate.

But, with a closely fought election in the offing and a desperate fight taking place for marginal seats, might candidates become more open about their beliefs if it means a few more votes?…

Read the full article here:

Will Christians swing the 2010 UK election? By Justin Parkinson. BBC News Online, 21 April 2010

Mexico: Child’s pregnancy fuels abortion row

A pregnant 10-year-old, allegedly raped by her stepfather, has become the latest lightning rod in the country’s heated abortion debate.

The girl’s stepfather has been arrested. But advocates on both sides of the issue say their battle is just beginning, CNN reports.

‘This girl is much more than an isolated case,’ said Adriana Ortiz-Ortega, a researcher at Mexico’s National Autonomous University who has written two books on abortion in Mexico, ‘and there is much more influence now from conservative groups that are trying to prevent the legalization of abortion.’

Abortion is legal in Mexico’s capital city, but prohibited or significantly restricted in most of the country’s states. The girl’s home state of Quintana Roo, on the Yucatan peninsula, allows abortion in cases of rape during the first 90 days of the pregnancy. But the 10-year-old girl is at 17.5 weeks, nearly a month past that limit.

Advocacy groups are calling for federal officials and the United Nations to investigate Quintana Roo’s handling of the matter, claiming officials did not inform her of her abortion rights. ‘We don’t know what is happening, and the institution that is supposed to provide support and care for these minors hasn’t been transparent. We’re really asking for accountability,’ said Maria Luisa Sanchez Fuentes, director of the Information Group on Reproductive Choice.

State Attorney General Francisco Alor Quezada said he did not know whether officials had told the girl she had the option of pursuing an abortion, and he did not know how far the girl was into her pregnancy when her mother reported the assault to authorities last month. He said the girl is in the custody of state protective services, and officials are closely monitoring her physical and psychological care.

Child protective services officials in Quintana Roo said in a statement last week that the girl and the fetus were in good health. But Quintana Roo state legislator Maria Hadad said the girl’s doctors aren’t telling the whole story. She said continuing the pregnancy could cause severe mental and physical health problems for the girl.

However, a subsequent article on Fox News reports that, according to pro-life activists in the country, the girl says she wants to have the baby. They say attorneys for abortion-rights activists have shown up at the girl’s home with plane tickets in hand in an attempt to whisk her away to get an abortion, but the child has said adamantly, ‘This is my baby. I’m having my baby. I will call my girl Alejandra’.

Women’s rights groups maintain that the girl is small even for an 11-year-old and that forcing her to give birth puts her life in danger. They say she is being pressured to have the child and was never informed of all her options.

But Patricia Lopez Mancera, director of the conservative Center for Women’s Studies and Comprehensive Formation in Cancun, says she has been in constant communication with the girl’s mother and the child welfare services institution where the girl currently lives.

Recounting the mother’s story of her daughter’s pregnancy and the girl’s decision to have the baby, she said, ‘Abortion was never an option. The girl and her mother never thought about it’.

The Roman Catholic Church vocally opposes abortion in Mexico, and the topic has long been controversial there, reports CNN. The debate has been particularly heated since 2007, when the nation’s more liberal capital city approved a law legalizing abortion during the first three months of pregnancy with no restrictions. That decision was challenged and ultimately upheld by the country’s Supreme Court in 2008.

Since 2007, 17 states have passed laws ‘protecting life beginning at conception,’ according to the Information Group on Reproductive Choice. Legislators in Quintana Roo, which is also is home to the popular resort city of Cancun, approved such changes to its constitution last year.

10-year-old’s pregnancy fuels Mexican abortion debate. CNN, 20 April 2010

11-Year-Old Mexican Rape Victim Wants to Keep Baby. FOXNews.com, 23 April 2010

India: Doctor arrested over ‘dumped fetuses’

Police in the western Indian state of Gujarat have arrested a doctor after 14 human fetuses were found in rubbish, BBC News Online reports.

The gynaecologist owned a clinic in the city of Ahmedabad where abortions were conducted over more than two decades. Police say he has admitted dumping the fetuses after they were damaged while he moved his clinic to a new building.

The doctor maintains the fetuses were legally aborted and did not follow illegal sex determination tests. The bodies have been sent for post-mortems.

Authorities said on Monday they suspected the foetuses may have been aborted because they were girls rather than boys, who have traditionally been favoured in India.

The doctor told police and public health officials that the fetuses were of babies legally aborted due to congenital abnormalities, and that they had been preserved in his clinic for about six years, the BBC’s Rathin Das reports from Ahmedabad. Police say they have charged the doctor with causing a public nuisance by not properly disposing of bio-medical waste.

It is claimed that female feticide has led to an unbalanced sex ratio in many northern districts of Gujarat, and in other states in India. Antenatal tests to determine the sex of babies is banned in India but the practice carries on despite the law. Some think that millions of female fetuses may have been aborted in India over the past 20 years.

Indian doctor arrested after foetuses found in Gujarat. BBC News Online, 20 April 2010

‘UK: Controversial sterilisation charity may come to Britain

Drug addiction experts have reacted with horror at the revelation that a charity worker who pays addicts to be sterilised is setting up a franchise in Britain, the Independent reports.

Project Prevention, which operates out of North Carolina, has stopped more than 3,500 drink and drug addicts from having children by paying them up to £200 to seek long term or permanent forms of contraception such as an IUD implant or full sterilisation. Once the addicts prove that an operation has been carried out they are awarded a cash sum which, the charity admits, usually goes towards feeding their habits.

Barbara Harris, the charity’s founder, believes encouraging drug addicts to seek sterilisation saves thousands of children from growing up within a damaged environment. She has adopted five children who were born to crack-addicted mothers. But critics say her approach automatically stigmatises all addicts as bad parents.

That argument has now crossed the Atlantic following the announcement that Mrs Harris has founded a freephone number for UK addicts who will be paid if they get themselves sterilised.

Andrew Horne, the director of Addaction, one of the UK’s largest addiction charities, lambasted the American charity’s approach.

‘There is no place for Project Prevention in the UK because their practices are morally reprehensible and irrelevant,’ he said. ‘Our first-hand experience shows that people can make positive changes with the right support – both for themselves and for their children. In fact, many of our clients stopped using drugs because they became a parent.’

Mrs Harris, who is currently in the UK, defended her work and claimed she was already talking to a number of unnamed drug agencies in London.

‘We’re going to make this offer to drug addicts, social workers, law enforcement,’ she said. ‘Anyone who comes in contact with these women can refer addicts to us now we have an 0800 number here in the UK. We hope the scheme will grow as much here as it did in the US, and that people will support us financially. We need the cash to pay the addicts.’

Charity that sterilises addicts to come to UK. Independent, 10 April 2010

UK: More GP surgeries intending to provide EMA

Data shows that four health trusts in England have requested licences to carry out early medical abortions in GP surgeries.

Another 11 are considering applying for a licence and two clinics are already up and running, according to figures obtained under the Freedom of Information Act by GP newspaper.

Early medical abortions involves two trips to a clinic, hours or a day apart, to take pills that induce miscarriage.

Responses were received from 114 primary care trusts and were analysed alongside data from the charity BPAS, which runs some of the clinics.

Previous research by GP suggested that six PCTs were considering or had applied for licences to provide early abortions.

BPAS has services in GP practices in Wolverhampton and Newcastle under contracts with primary care trusts (PCTs), and has applied to run a service in Basingstoke. Each year, the charity provides around 13,000 early medical abortions under nine weeks’ gestation. BPAS also provides pregnancy advisory bureaux (PAB) services from GP premises in Coventry, Telford, Shrewsbury and Bath.

Ann Furedi, chief executive of BPAS, said the ‘abortion pill’ method is safe and effective. She said:

‘It makes perfect sense for the abortion pill to be available from GP, health centres and family planning clinics where doctors have the time and knowledge to counsel women properly and provide 24/7 advice and support for their patients.

‘It must be borne in mind though, that the abortion pill is not “abortion lite”. It is not a cheaper or easier option that could be slotted into an eight-minute GP appointment - it requires no more, but no less care than other abortion methods.’

‘Early abortion’ licences sought. Press Association, 15 April 2010

GP newspaper investigation results, 15 April 2010.

UK: Campaign to arrest the Pope

Leading atheist Richard Dawkins has backed a campaign to have the Pope arrested for ‘crimes against humanity’ when he visits the UK later this year.

Professor Dawkins said he ‘whole-heartedly’ backed the initiative led by atheist Christopher Hitchens, BBC News Online reports.

UK human rights lawyers are preparing a case to charge Pope Benedict XVI over his alleged cover-up of sexual abuse in the Catholic church. Campaigners hope to cast a shadow over the Pope’s planned visit to the UK in September - the first visit by a Pope since 1982.

Prof Dawkins wrote on his blog: ‘I am optimistic that we shall raise public consciousness to the point where the British government will find it very awkward indeed to go ahead with the Pope’s visit.’ And writing in the Guardian, columnist George Monbiot wrote: ‘Picture the pope awaiting trial in British prison, and you begin to grasp the implications of the radical idea that has never been applied: equality before the law.’

The BBC’s religious affairs correspondent Robert Pigott said the anti-Pope campaign could be seen as a mischievous attempt to create an ‘air of criminality’ around the Pope. ‘The controversy over alleged Papal involvement in the cover-up of child sex abuse is providing atheists with a stick with which to beat religion,’ he said.

The Pope’s visit was announced shortly before allegations surfaced that he had signed a letter which delayed the punishment of a paedophile priest in the US. This followed a series of child abuse scandals involving the Catholic church in the US, the Irish Republic, Germany and Norway, reports BBC News Online.

The Vatican has defended the Pope, saying the Pope is willing to meet more victims of clerical abuse, while the Church has published an internet guide as to how bishops deal with accusations of sexual abuse.

Barrister Geoffrey Robertson and solicitor Mark Stephens are considering whether they could either ask the Crown Prosecution Service to initiate criminal proceedings against the Pope; launch their own civil action or refer his case to the International Criminal Court.

Author Christopher Hitchens said he does not believe the Vatican to be a legal state which raises questions as to whether the Pope, as head of state, could claim diplomatic immunity. He said:

‘The UN at its inception refused membership to the Vatican but has allowed it a unique “observer status”, permitting it to become signatory to treaties such as the Law of the Sea and (ironically) the Convention on the Rights of the Child, and to speak and vote at UN conferences where it promotes its controversial dogmas on abortion, contraception and homosexuality.’

But Dr William Oddie, former editor of The Catholic Herald, said the campaign demonstrated how ‘wonderfully lunatic’ both Christopher Hitchens and Professor Dawkins were.

‘What’s lawful is what is lawfully agreed by lawful authorities, in this case Italian law - the government of Italy - and secondly, international law, determined by the United Nations. Both legal authorities accept the Vatican is a legal state. Christopher Hitchens is entitled to say it shouldn’t be one, but he can’t say it isn’t one - it’s like people in a lunatic society saying they are Napoleon,’ he said.

The Vatican has ruled out any possibility of a papal resignation over the scandal.

Atheist Richard Dawkins backs campaign to arrest Pope. BBC News Online, 13 April 2010.

UK: Tory party leader calls for review of abortion time limit

In an interview with the Catholic Herald, David Cameron discussed conscience issues such as abortion and euthanasia.

Asked by a reader of the Catholic Herald whether he would press for a reduction in the abortion limit, Cameron said there should be a review. ‘I think that the way medical science and technology have developed in the past few decades does mean that an upper limit of 20 or 22 weeks would be sensible,’ he said.

He added that it was important that MPs have a free vote on abortion, as well as euthanasia. He said his personal view was ‘that if assisted dying is legalised, there is a danger that terminally ill people may feel pressurised into ending their lives if they feel they’ve become a burden on loved ones. I don’t believe anyone should be put in this position.’

The Conservative leader said he had no plans to overturn the 2008 Human Fertilisation and Embryology Act, which had allowed for the creation of human-animal embryos and legally fatherless children. But he said it was ‘a contentious Act, and there were a number of things in it which I for one had some concerns with’.

Regarding the Children, Schools and Families Bill, which many Catholics feared would force schools to teach about contraception and abortion, Mr Cameron said faith schools would have the freedom to teach such issues ‘in line with their values’.

‘I do think that sex and relationship education is an important part of learning about responsibility,’ he said. ‘But schools should be allowed to teach it in a way that’s consistent with their beliefs, and parents should be free to decide whether or not their children should take part in these lessons. I think parents who have chosen a faith-based education for their children should have that decision respected. I’m a big supporter of faith schools and I think it’s really important that their rights are protected in this way.’

The issue of fetal viability was the subject of much discussion in the run up to the Human Fertilisation and Embryology Bill Committee Stage debate in the House of Commons in May 2008, including a report by the cross-party Commons Science and Technology Committee, to which BPAS and the wider medical and nursing profession submitted evidence. On this issue, the report concluded ‘while survival rates at 24 weeks (the current upper limit for abortion) and over have improved since 1990, survival rates (viability) have not done so below that gestational point. The Committee concludes that there is no scientific basis - on the grounds on viability - to reduce the upper time limit.’

David Cameron: ‘I will defend faith schools’, by Ed West. Catholic Herald, 9 April 2010

UK: Study points to limitations of chlamydia screening programme

Women should be tested for chlamydia every time they have a new sexual partner to cut their chances of pelvic disease, UK researchers say.

A study of 2,500 students found that annual screening is not enough to prevent cases of pelvic inflammatory disease, which can cause infertility, BBC News Online reports. In those who were found to have chlamydia, treatment cut the risk of pelvic disease by 80%.

The researchers from St George’s, University of London, concluded that most cases of pelvic inflammatory disease were in women who did not have chlamydia when they were tested a year earlier. The findings, published in the British Medical Journal, suggested they may have become infected in the 12 months after screening.

The researchers recruited sexually active female students between the ages of 16 to 27 from 20 universities and colleges in London. They were swabbed at the beginning of the study and tested for pelvic inflammatory disease, which as well as infertility can cause chronic pain and increase the risk of ectopic pregnancy, a year later.

The researchers found that most cases of pelvic inflammatory disease occurred in women who tested negative for chlamydia when they were initially tested. They concluded:

‘Although some evidence suggests that screening for chlamydia reduces rates of pelvic inflammatory disease, especially in women with chlamydial infection at baseline, the effectiveness of a single chlamydia test in preventing pelvic inflammatory disease over 12 months may have been overestimated’.

BBC News Online reports that study leader Professor Pippa Oakeshott, who also works as a GP, said: ‘The crucial message is that individuals should get tested every time they have a new sexual partner.’ But she added that chlamydia was not the only cause of pelvic inflammatory disease. ‘It’s probably several bacteria that cause it, and we should probably be screening for other things, but chlamydia and gonorrhoea is a good start.’

A spokesman for the Health Protection Agency said the findings reinforced the testing policy of the National Chlamydia Screening Programme, which was launched in 2003. ‘The study, looking at a single annual test, shows the importance of the programme’s approach to testing annually or on change of sexual partner because most cases of pelvic inflammatory disease occurred in women who initially tested negative for chlamydia.’

Last year the National Audit Office criticised the screening programme for duplicating effort and failing to test as many of the under-25 target group in England as it should have.

Chlamydia test after every new partner call. BBC News Online, 8 April 2010

Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. Pippa Oakeshott, Sally Kerry, Adamma Aghaizu, Helen Atherton, Sima Hay, David Taylor-Robinson, Ian Simms, Phillip Hay. BMJ 2010;340:c1642

UK: Sex education reforms shelved

The Secretary of State for Children, Schools and Families has been forced to drop key reforms to sex education in schools. 

Ed Balls confirmed that the controversial plan was among the measures being shelved in order to push through legislation before parliament is dissolved for the general election.

A guarantee of one-to-one tuition for pupils who fall behind in English and maths is also being removed from the Children, Schools and Families Bill, along with moves to beef up parenting orders.

In a letter to his Conservative shadow Michael Gove, Mr Balls wrote:

‘I am especially disappointed that, despite our conversation, you could not agree to make Personal Social Health and Economic Education (PSHE) statutory in all state-funded schools.

‘There is now widespread agreement that statutory PSHE is essential to prepare young people for adult life, and our reforms would ensure that by reducing the age of parental opt-out to 15, all children receive at least one year of compulsory sex and relationship education (SRE).

‘This is a very significant setback, which will deny many young people proper and balanced sex and relationships education.’

Sex education reforms dropped. Press Association, 7 April 2010

Also read:

UK: Sex education controversy continues. Abortion Review, 24 February 2010.

USA: Risk of miscarriage with bivalent vaccine against human papillomavirus (HPV) types 16 and 18

The authors concluded that there is no evidence overall for an association between HPV vaccination and risk of miscarriage. From the British Medical Journal.

The study set out to assess whether vaccination against human papillomavirus (HPV) increases the risk of miscarriage.

This was a pooled analysis of two multicentre, phase three masked randomised controlled trials SETTING: Multicentre trials in several continents and in Costa Rica. Participants were 26 130 women aged 15-25 at enrolment; 3599 pregnancies eligible for analysis.

Participants were randomly assigned to receive three doses of bivalent HPV 16/18 VLP vaccine with AS04 adjuvant (n=13 075) or hepatitis A vaccine as control (n=13 055) over six months. The main outcome measures were miscarriage and other pregnancy outcomes.

The estimated rate of miscarriage was 11.5% in pregnancies in women in the HPV arm and 10.2% in the control arm. The one sided P value for the primary analysis was 0.16; thus, overall, there was no significant increase in miscarriage among women assigned to the HPV vaccine arm. In secondary descriptive analyses, miscarriage rates were 14.7% in the HPV vaccine arm and 9.1% in the control arm in pregnancies that began within three months after nearest vaccination.

The authors concluded that there is no evidence overall for an association between HPV vaccination and risk of miscarriage.

TRIAL REGISTRATION: Clinical Trials NCT00128661 and NCT00122681.

Division of Cancer Epidemiology and Genetics, National Cancer Institute, 6120 Executive Blvd, Rockville, MD 20852, USA.

[Full text] Risk of miscarriage with bivalent vaccine against human papillomavirus (HPV) types 16 and 18: pooled analysis of two randomised controlled trials. Wacholder S, Chen BE, Wilcox A, Macones G, Gonzalez P, Befano B, Hildesheim A, Rodríguez AC, Solomon D, Herrero R, Schiffman M; CVT group. BMJ. 2010 Mar 2;340:c712. doi: 10.1136/bmj.c712.

Comment in: BMJ. 2010;340:c1666.

Taiwan: Sonographic quantification of endometrial changes after abortion

The study set out to examine the diagnostic feasibility of sonographic gray scale histograms to assess changes in the endometrium following abortion induced by mifepristone and misoprostol. From Acta Obstetricia et Gynecologica Scandinavica. 

This was a retrospective study, set in Taipei Medical University-Wan Fang academic medical centre. A total of 109 patients who matched eligibility criteria were divided into three groups: (a) complete abortion, (b) normal menstrual cycles, and (c) incomplete abortion.

Ultrasonographic examination of the uterus with fixed settings on each patient and sonographic gray scale histograms with image analysis software, using multivariate analysis by the partial least square model. Main outcome measures were thickness, brightness, area and distribution of pixels of the endometrium and its contents.

The results found that the groups could be discriminated (p < 0.01, Kruskal-Wallis test) using the analysed gray scale histograms. The classification between complete and incomplete abortion reached 97% sensitivity and 100% specificity.

The authors concluded that partial least square analysis of gray scale histograms of the endometrium in ultrasonographic images is useful in assessing endometrial changes.

Taipei Medical University-Wan Fang Medical Center, Department of Obstetrics and Gynecology, Taipei, Taiwan.

Sonographic quantification of endometrial changes after abortion with computer-assisted image analysis. Chou SY, Chen CY, Hsu MI, Chow PK, Hsu CS, Chiang HK. Acta Obstetricia et Gynecologica Scandinavica. 2010 Mar;89(3):385-9.

UK: New guidance for pharmacists retains ‘conscience clause’

Pharmacists across the UK have been told they can continue to refuse to prescribe items that might clash with their personal religious beliefs.

A revised code of conduct from the new industry regulator will allow staff to opt out of providing items such as the morning-after pill and contraception, BBC News Online reports. But they may in future have to give customers details of alternative shops.

The General Pharmaceutical Council (GPhC) is to take over the regulation of pharmacists, pharmacy technicians and the registration of pharmacy premises from the Royal Pharmaceutical Society later this year.

The National Secular Society wanted the General Pharmaceutical Council to scrap the so-called ‘conscience clause’. Under its new code, pharmacists with strong religious principles will still be able to continue to refuse to sell or prescribe products if they feel that doing so would contradict their beliefs. But the GPhC says pharmacists who refuse services could be obliged to tell patients where they can access them and it plans to consult more widely on the issue.

John McManus, BBC Religious Affairs producer, writes:

‘I have been told that the so-called “conscience clause” is only used by a very small number of pharmacists who feel their religious beliefs would be undermined by giving out contraception. Similarly, doctors have long been able to both turn down training in abortion procedures, or carry them out, if they have ethical objections.

‘Yet critics argue that even pharmacists working for private retail chains are providing a public service, often in conjunction with local GPs and hospitals, and should be ready to put their own objections to one side.

‘The new regulator says it is aware that the clause can be controversial, which is why it will consult more widely on the issue later in the year. And the Royal Society of Pharmacists insist that members who “opt-out” of providing services must consider what effect their actions may have on a patient.

‘For now though, there is still a chance that members of the public wanting various forms of contraception could be turned away by their local chemist.’

The issue was