Spain: Senate approves new abortion law

Spain on 24 February approved a sweeping new law that allows the procedure without restrictions up to 14 weeks and gives 16- and 17-year-olds the right to have abortions without parental consent. 

The bill brings the country in line with northern Europe is the latest of a series of bold social reforms undertaken by Socialist Prime Minister Jose Luis Rodriguez Zapatero, who first took office in 2004 and has ruffled feathers among many in the traditionally Catholic country, Associated Press reports.

Carmen Duenas, a spokeswoman for the leading conservative opposition Popular Party in the Senate, accused the government of trying ‘to bring in unrestricted abortion’. ‘The government wants to do away with one of the pillars of Spanish society, which is the family,’ she said. But Senator Leire Pajin, the ruling Socialist party’s No. 3, said the new law ‘paid off an outstanding debt’ to women, offering them a choice and bringing an end to illegal abortions.

Under the previous law, which dates back to 1985, Spanish women could in theory go to jail for getting an abortion outside certain strict limits — up to week 12 in case of rape and week 22 in the case of fetal abnormality. But abortion has been in effect widely available because women can assert mental distress as sole grounds for having an abortion, regardless of how late the pregnancy is. Most of the more than 100,000 abortions carried out each year in Spain were early-term ones that fell under this category, AP reports.

While the new law has been widely reported as a liberalisation of the law, some reproductive choice advocates have cautioned that, in practice, it may restrict women’s access to abortion in later gestations. Before the reforms, although there was no ‘right’ to abortion, the law allowed abortion without time limit in broadly the same circumstances as the British law up to 24 weeks. This meant that doctors prepared to interpret it liberally could, and did, offer access way beyond the 14 weeks that the new law permits. Women from throughout Europe have been known to travel to Spain to have an abortion that would be denied in their home country.

The new bill provides for greater regulation. It permits abortion up to 22 weeks if two doctors certify there is a serious threat to the health of the mother, or fetal malformation. Beyond 22 weeks, it would be allowed only doctors certify fetal malformation deemed incompatible with life or the fetus were diagnosed with an extremely serious or incurable disease.

The new bill was automatically approved when a majority of senators rejected three proposals by conservative parties to have it vetoed, and then rejected a total of 88 amendments, AP reports. It will be published in the state bulletin next month and will take effect four months later.

The part of the new law allowing 16- and 17-year-olds to have abortions without parental consent puts Spain in line with other European countries such as Germany, Britain and France. It was among the bill’s most controversial elements. In the end, the government amended it so that minors must inform their parents or legal guardian if they plan to undergo an abortion, but do not need their permission. They are, however, exempt from this requisite if they can show that fulfilling it would expose them to violence within their family, threats or coercion.

Spanish Senate approves new abortion law. Associated Press, 25 February 2010

UK: Hospital faces complaint about confidentiality breach

An investigation has begun into claims that a hospital worker broke confidentiality to tell a teenage patient’s family about her abortion.

The 19-year-old mother-of-two, said her grandmother, a Catholic, was told about it by an administration worker at Prince Charles hospital in Merthyr, BBC News Online reports. She is now considering taking further action against the hospital trust.

Cwm Taf NHS Trust said it was ‘engaged’ with the woman as part of the complaints procedure.

The patient, whose identity is not being made public, said her life had been ‘ruined’ by the revelations, with her grandmother ‘totally disowning’ her. Her children are aged 18 months and almost three.

She said she now regretted having the abortion because of the impact it had had on her family. ‘It was the hardest decision in the world. When I found out I was pregnant again, I didn’t think I would cope. Me and my boyfriend talked about having a termination. It certainly wasn’t something we did lightly.’

The woman added: ‘I’m a good mum and I love my kids. But I couldn’t have another baby. My boyfriend was off to the Army - I would have been left on my own with three babies.’

She said they decided not to tell her family about the medical abortion three months into the pregnancy. Instead she told her parents that she had gone for tests for a stomach complaint. The next day she visited her grandmother in Merthyr, and when asked, said her hospital tests had gone all right, BBC News Online reports.

She said her grandmother called out ‘liar’. ‘She told me her friend working at the hospital had told her all about it. She is a very strong Catholic and couldn’t forgive me.’

The woman said she had made a formal complaint to the hospital and had an apology. But she said she felt like she has been ‘fobbed off’. ‘Anyone who goes in hospital should be entitled to privacy and confidentiality. But a termination is even more personal and delicate - people don’t understand what you are going through deciding not to have a baby.’

A hospital spokesman said: ‘We can confirm that we are currently engaged with her as part of the complaints procedure. Consequently it would be in appropriate for us to comment further on this case.’

Hospital worker ‘told family of teenager’s abortion’. BBC News Online, 1 February 2010

UK: New statistics show fall in teenage pregnancy rate

The number of teenage pregnancies in England and Wales has fallen by 4%, according to figures released by the Office for National Statistics (ONS).

A total of 41,325 women under 18 fell pregnant in 2008, down 3.9% from 42,988 in 2007, the figures show. Of these young women 49% had an abortion, compared with 50% in 2007.

The government had pledged in 1999 to halve teenage pregnancy rates among under-18s in England by this year but is widely expected to miss that target, BBC News Online reports.

The ONS data shows for every 1,000 girls aged between 15 and 17 in England and Wales, there were just over 40 pregnancies.

The North East had the highest under-18 conception rate in 2008, with 49 per 1,000 women age 15-17 falling pregnant. The East of England had the lowest rate with 31.4 per 1,000 young women getting pregnant.

The number of girls aged 13 to 15 getting pregnant fell by 6% in 2008, with 7.8 conceptions per 1,000 girls compared with 8.3 in 2007. Since 2002 the number of teenage girls falling pregnant in England and Wales has been steadily falling, despite a slight rise in 2007.

The ONS statistics show there were an estimated 887,800 conceptions among women of all age groups in England and Wales in 2008, a decrease of 0.9% on the 2007 figure of 895,900.

Conception rates decreased in all age groups between 2007 and 2008, with the exception of women aged 40 and above, where conceptions remained at 12.6 per 1,000 women. While conception rates in the 30-34 and 35-39 age groups fell slightly in 2008, they have risen steadily over the past 10 years.

The number of conceptions outside marriage in England and Wales increased slightly from 56% in 2007 to 57% in 2008.

The number of conceptions outside of marriage which resulted in the birth of a chid was 67%, compared with 93% of conceptions inside marriage. The proportion of all conceptions resulting in a birth was 78%.

The ONS figures for conceptions cover those that result in a live or still birth or are terminated by abortion; they do not include miscarriages or illegal abortions.

Although the number of teenage pregnancies in England and Wales fell in 2008, the government is highly unlikely to meet its 1999 pledge to halve teenage pregnancies in England by 2010. Figures from the Department of Children, Schools and Families show rates in England are down by just 13.3% from 1999 to 2008.

The government allocated £260m to reducing teenage pregnancy and, in 2009, ministers announced an extra £20.5m funding package for contraception resources.

Schools Secretary Ed Balls defended ministers’ record and said the statistics showed the rate of teenage pregnancies was now the lowest it had been for well over a decade.

But Mr Balls conceded it was going to be ‘really hard’ to achieve the pledged ‘ambitious target’ of a 50% decline on 1998 figures by 2010.

Children’s Minister Dawn Primarolo welcomed the ONS figures, saying teenage pregnancy was no longer a rising problem.

‘Last year’s increase was very disappointing so I am particularly pleased that today’s statistics put us back on track,’ she said.

Gill Frances, chairwoman of the Teenage Pregnancy Independent Advisory Group, said it also welcomed the teenage pregnancy strategy being back on its long term downward trend.

‘Nationally, statutory Sex and Relationships Education will give an extra benefit and government must also ensure all young people have access to contraceptive and sexual health services,’ she said.

Teenage pregnancy rate falls. BBC News Online, 24 February 2010.

Conceptions in England and Wales, 2008. ONS, 24 February 2010 [.pdf]

UK: Sex education controversy continues

Children’s Secretary Ed Balls has denied that plans for compulsory sex education in England’s schools have been watered down.

But an amendment to a government bill gives faith schools more freedom to tailor teaching to their own beliefs.

Pressure groups claim this amendment would allow faith schools to ignore requirements in the bill to teach it in a balanced way, respecting diversity.

Mr Balls dismissed suggestions that the amendment to the Children, Schools and Families Bill, which was revealed by BBC News Online on 19 February, represented an ‘opt out’ for faith schools.

He told the Today programme:

‘A Catholic faith school can say to their pupils we believe as a religion contraception is wrong but what they can’t do is therefore say that they are not going to teach them about contraception to children and how to access contraception.

What this changes is that for the first time these schools cannot just ignore these issues or teach only one side of the argument. They also have to teach that there are different views on homosexuality. They cannot teach homophobia. They must explain civil partnership.’

But opponents say this requirement was already in the Children, Schools and Families Bill.

Rabbi Dr Jonathan Romain, of the Accord Coalition which calls for an end to what it sees as religious discrimination in school staffing and admissions, told Today he was ‘astonished and saddened’ that Mr Balls had chosen effectively to give faith schools an opt-out.

‘If a school doesn’t approve of contraception or abortion or homosexuality, then it can give that message or it can omit certain facts. We know there are some faith schools which take a very negative view.’

Under the plans, all schools are to be required to teach children aged seven to 11 about relationships including marriage, same sex and civil partnerships, divorce and separation under Personal, Social, Health and Economic Education. Secondary school pupils are to learn about sexual activity, reproduction, contraception as well as same sex relationships.

The bill states the subject is to be taught in a way that promotes equality, accepts diversity and emphasises both rights and responsibilities.

This requirement could have been problematic for schools governed by religions that are specifically opposed to homosexuality and contraception. About a third of schools in England are faith schools.

In a statement on its website, the Catholic Education Service says the amendment, which was tabled by Children’s Secretary Ed Balls, was secured after a period of ‘extensive lobbying’. But it refused to comment on the issue BBC News Online reports.

Liberal Democrat Children’s spokesman David Laws said the amendment was ‘a serious and undesirable U-turn’. He told Today:

‘This government hasn’t had a bad record over the years in trying to challenge things like homophobia. Now, with this amendment it’s undermined a lot potentially, that it’s been achieving. I think it will upset many people who believe that in today’s Britain we should have a society where the taxpayer should not be subsidising prejudice.’

The British Humanist Association is also among those who have criticised the amendment. Its chief executive Andrew Copson said the amendment effectively gave a licence to faith schools to teach sex and relationships educations in ways that were homophobic, gender discriminatory and violated principles of human rights.

Sex education ‘not watered down,’ says Ed Balls. BBC News Online, 23 February 2010

Ireland: Attorney general speaks about X case

The attorney general who challenged a 14-year-old rape victim’s right to travel to England for an abortion in 1992 has said that he regrets the sadness caused, but insists he was only doing his duty, the Sunday Times reports.

Harry Whelehan, who was attorney general in the Albert Reynolds-led Fianna Fail/Labour coalition government, has justified his role in the infamous X case, saying he did what was constitutionally required.

‘I’m not prepared to say I regret having to do my duty,’ he says in an RTE documentary about the case, broadcast on 22 February. ‘I do of course regret the upset, the sadness, the trauma, which was visited on everybody involved but that’s something which I can’t do anything more about.’

In February 1992, after the case was brought to his attention by the Director of Public Prosecutions (DPP), Whelehan sought a High Court injunction to prevent the girl, known only as Miss X, from leaving the country for an abortion. The girl had been raped by a friend of her father in Rathfarnham when she was 13.

Less than a decade earlier, a referendum was passed amending Article 40.3.3 of the Irish constitution to give protection to the unborn child.

‘The problem was stark,’ Whelehan told the Scannal programme. ‘There was an unborn child with a constitutional right to life. There was nobody to advocate the right of that child to be born other than the attorney general.

‘I don’t want this to sound harsh but where the mother of the child, who is entitled to have its life protected, decides to seek an abortion the only mechanism in our system is for the attorney general to intervene and make a case for the child to be born alive.’

Seán Duignan, who was government press secretary at the time, told the programme: ‘I remember Harry and [Albert Reynolds] kicking it back and forward, arguing about it and Albert going “Harry, you’ve got to think politically occasionally” and Harry saying “No, you can’t get over the legal and the constitutional implications, taoiseach”.

‘Both sides of the house were adamant that Harry should have taken advice. What they really meant by that is that he should have delayed, that the file should have dropped behind a radiator for a while… at least until the girl was out of the country and that she had her abortion.’

Whelehan acknowledges that there was pressure on him to turn a blind eye, the Sunday Times reports, but that would have meant failing to do his duty. ‘I know it was suggested by many people that I should have done nothing and that could never have been a proper or honourable action, nor could it have in any way put me in a position of discharging my constitutional obligation to protect or to at least seek to protect the right of that unborn child to be born,’ he says.

The case of the Attorney General v X was heard in the High court in February 1992. Even though the girl threatened suicide, Justice Declan Costello upheld the rights of the unborn child and granted the injunction. Banned from travelling for 10 months, Miss X appealed to the Supreme Court and it lifted the High Court order by a four-to-one majority.

The majority opinion held that a woman had a right to an abortion under Article 40.3.3 if there was ‘a real and substantial risk’ to her life. This was never subsequently provided for in Irish legislation by subsequent governments.

X case judge Harry Whelehan: I was only doing my duty. The Sunday Times, 21 February 2010

Clinical Update: Vacuum aspiration under local anaesthetic

In her Q&A column for Abortion Review, BPAS’ Medical Director Patricia Lohr examines developments and discussions in abortion provision. 

Q) What is vacuum aspiration under local anaesthetic?

Vacuum aspiration is a method of abortion where a cannula is inserted into the uterus and gentle suction is applied to remove the pregnancy. The suction is created by an electric vacuum machine or a hand-held syringe called a manual vacuum aspirator.

Pain is managed with a combination of oral analgesia (such as ibuprofen) and local anaesthetic (lidocaine) injected into or next to the cervix. Lidocaine gel can also be used in the cervical canal. The injection or gel reduces discomfort from the passage of instruments or dilators through the cervix while the analgesic is intended to calm the pain from uterine cramping during the evacuation.

Another important aspect of pain control during these procedures is good communication with the woman about what is happening and ‘vocal local’ - comforting or distracting conversation with the woman which is frequently done by an assistant and/or the surgeon.

Q) What advantages does this have over general anaesthetic?

Probably the greatest advantage of local over general anaesthetic is the length of the recovery period. The recovery period from a general anaesthetic is typically 2 hours but only about 30 minutes, or sometimes less, with a local anaesthetic.

In addition, women do not experience drowsiness or other after-effects of sedating medication given with a general anaesthetic. This may help women feel more in control during the procedure and be important for women who need to drive after the procedure, work, or care for children or other family members or who do not have an escort to look after them afterwards.

There is also no need to fast for a local anaesthetic. This can be very helpful for women with medical problems, such as diabetes. Finally, for some women, it may be safer to have a procedure under local rather than general anaesthesia, for example very obese women.

Q) What are the disadvantages?

Administration of analgesia and local anaesthetic reduces the pain associated with a vacuum aspiration but does not remove it completely. Experiencing any pain may be unacceptable to some women, as may remaining awake during the entire procedure.

Although a vacuum aspiration is short in duration (about 10 minutes from start to finish, with the aspiration lasting only a few minutes), women who have this procedure will need to remain calm and controlled throughout for the procedure to be performed safely. It is important that women understand what they will experience during a procedure under local anaesthetic and actively choose to have their abortion by this method.

Q) To what gestation can vacuum aspiration under local anaesthetic be performed?

At BPAS, we currently offer manual vacuum aspiration under local anaesthetic to 12 weeks’ gestation. Electric vacuum aspiration can be performed to about 14-15 weeks’ gestation. This isn’t to say that there is an absolute gestational age limit to which abortion procedures under local anaesthetic can be performed. It is even possible to perform dilatation and evacuation under local anaesthetic safely and satisfactorily at advanced gestational ages.

Q) What is the scope of BPAS’ provision of this method?

At present, most surgical abortions performed at BPAS are done under general anaesthetic but our provision of local anaesthetic procedures is increasing. I would like to see BPAS expand the gestational ages at which abortions are performed under local anaesthetic as it offers yet another option, along with medical abortion, general anaesthetic and conscious sedation, for a woman to have the abortion procedure she feels is right for her.

It may also allow us to care for some women with medical problems who cannot have a general anaesthetic in a freestanding clinic access their abortion with us. This is important because it can be difficult to locate an NHS provider for some women, particularly after about 16 weeks’ gestation.

This article appears in the Winter 2010 print edition of Abortion Review, which can be downloaded for free here.

USA: Anti-abortion campaign targets black community

The UK Independent reports on a controversial poster campaign in Georgia.

The message on dozens of billboards across Atlanta is provocative: black children are an ‘endangered species’. The ads featuring a young black child are an effort by the anti-abortion movement to use race to rally support within the black community.

The reaction from black leaders was mixed, but the Too Many Aborted campaign, which so far is unique only to Georgia, is drawing support from other anti-abortion groups across the country, the Independent says.

The billboards went up in Atlanta in February and urge black women to ‘get outraged’.

The effort is sponsored by Georgia Right to Life, which also is pushing legislation that aims to ban abortions based on race.

Black women accounted for the majority of abortions in Georgia in 2006, even though blacks make up just a third of the state’s population, according to the US Centres for Disease Control and Prevention. Nationally, black women were more than three times as likely to get an abortion in 2006 compared with white women, according to the CDC.

Anti-abortion advocates say the procedure has always been linked to race. They claim Planned Parenthood founder Margaret Sanger wanted to eradicate minorities by putting birth control clinics in their neighbourhoods, a charge that Planned Parenthood denies.

‘The language in the billboard is using messages of fear and shame to target women of colour,’ said Leola Reis, a spokeswoman for Planned Parenthood of Georgia. ‘If we want to reduce the number of abortions and unintended pregnancies, we need to work as a community to make sure we get quality affordable health care services to as many women and men as possible.’

US anti-abortion activists target black community. Independent, 15 February 2010

UK: Tory Party under fire for teen pregnancy statistics error

Pregnancy advice groups and child welfare organisations have criticised the Conservatives over their mistaken assertion that more than half of all girls in deprived areas fall pregnant before the age of 18. 

The claim — ten times the true number — is made repeatedly in a campaigning document entitled Labour’s Two Nations, released alongside a new poster campaign launched by David Cameron today that criticises Labour for failing the poor, reports The Times (London).

The proportion of young girls who become pregnant in the UK’s ten poorest areas is in fact 5.4 per cent.

Ann Furedi, chief executive of BPAS, said:

‘The very fact that people can repeatedly get the facts on teenage pregnancy so wrong — ten times wrong — shows that their stereotyped expectations of young people are totally out of sync with reality.’

Britain has one of the highest teenage pregnancy rates in Europe, with more than 41 girls in every 1,000 aged 15 to 17 falling pregnant each year.

The Two Nations document claims: ‘In the most deprived areas, 54 per cent are likely to fall pregnant before the age of 18, compared to just 19 per cent in the least deprived areas.’

The claim was based on statistics for the ten most deprived areas of the UK — Birmingham, Easington, Hackney, Islington, Knowsley, Liverpool, Manchester, Middlesbrough, Newham and Tower Hamlets. The claim was made three times in the document, The Times reports.

The latter figure of a 19 per cent pregnancy rate in the least deprived areas is also wrong. In the London borough of Richmond upon Thames, one of Britain’s least deprived areas, the true rate of teenage pregnancy is 1.6 per cent, or 15.7 per 1,000, while in rural Rutland it is 1.8 per cent or 18.1 per 1,000.

George Osborne, the Shadow Chancellor, was unrepentant about the error, claiming that the overall point was clear. ‘The whole document is making the argument that the whole gap between rich and poor in this country is growing after 13 years of Labour government,’ Mr Osborne told Sky News.

A Conservative Party spokesman agreed, saying: ‘A decimal point was left out in a calculation. It makes no difference at all to the conclusions of a wide-ranging report which shows that Labour have consistently let down the poorest in Britain.’

But Harriet Harman, the Leader of the Commons, said that a series of errors showed that the Conservatives were misleading the public.

‘They are determined always to put out a black view of Britain, to put Britain down, and because of that they just can’t be trusted with the statistics,’ she said. ‘This comes hard on the heels of them being told off by the UK Statistics Authority for saying that violent crime was going up when in fact it was going down.’

Tories under attack over teen pregnancy blunder. The Times (London), 15 February 2010

Too many people? No, too many Malthusians

Since 200 AD, scaremongers have been describing human beings as ‘burdensome to the world’. They were wrong then, and they’re still wrong today. Commentary by Brendan O’Neill. 

On 12 November 2009, Brendan O’Neill, editor of spiked, debated Roger Martin, chairman of the Optimum Population Trust, at the Wellcome Collection in London. His speech is published below.

In the year 200 AD, there were approximately 180million human beings on the planet Earth. And at that time a Christian philosopher called Tertullian argued: ‘We are burdensome to the world, the resources are scarcely adequate for us… already nature does not sustain us.’ In other words, there were too many people for the planet to cope with and we were bleeding Mother Nature dry.

Well today, nearly 180million people live in the Eastern Half of the United States alone, in the 26 states that lie to the east of the Mississippi River. And far from facing hunger or destitution, many of these people – especially the 1.7million who live on the tiny island of Manhattan – have quite nice lives.

In the early 1800s, there were approximately 980million human beings on the planet Earth. One of them was the population scaremonger Thomas Malthus, who argued that if too many more people were born then ‘premature death would visit mankind’ – there would be food shortages, ‘epidemics, pestilence and plagues’, which would ‘sweep off tens of thousands [of people]’.

Well today, more than the entire world population of Malthus’s era now lives in China alone: there are 1.3billion human beings in China. And far from facing pestilence, plagues and starvation, the living standards of many Chinese have improved immensely over the past few decades. In 1949 life expectancy in China was 36.5 years; today it is 73.4 years. In 1978 China had 193 cities; today it has 655 cities. Over the past 30 years, China has raised a further 235million of its citizens out of absolute poverty – a remarkable historic leap forward for humanity.

In 1971 there were approximately 3.6billion human beings on the planet Earth. And at that time Paul Ehrlich, a patron of the Optimum Population Trust and author of a book called The Population Bomb, wrote about his ‘shocking’ visit to New Delhi in India. He said: ‘The streets seemed alive with people. People eating, people washing, people sleeping. People visiting, arguing, screaming. People thrusting their hands through the taxi window, begging. People defecating and urinating. People clinging to buses. People herding animals. People, people, people, people. As we moved slowly through the mob, [we wondered] would we ever get to our hotel…?’

You’ll be pleased to know that Paul Ehrlich did make it to his hotel, through the mob of strange brown people shitting in the streets, and he later wrote in his book that as a result of overpopulation ‘hundreds of millions of people will starve to death’. He said India couldn’t possibly feed all its people and would experience some kind of collapse around 1980.

Well today, the world population is almost double what it was in 1971 – then it was 3.6billion, today it is 6.7billion – and while there are still social problems of poverty and malnutrition, hundreds of millions of people are not starving to death. As for India, she is doing quite well for herself. When Ehrlich was writing in 1971 there were 550million people in India; today there are 1.1billion. Yes there’s still poverty, but Indians are not starving; in fact India has made some important economic and social leaps forward and both life expectancy and living standards have improved in that vast nation.

What this potted history of population scaremongering ought to demonstrate is this: Malthusians are always wrong about everything.

The extent of their wrongness cannot be overstated. They have continually claimed that too many people will lead to increased hunger and destitution, yet the precise opposite has happened: world population has risen exponentially over the past 40 years and in the same period a great many people’s living standards and life expectancies have improved enormously. Even in the Third World there has been improvement – not nearly enough, of course, but improvement nonetheless. The lesson of history seems to be that more and more people are a good thing; more and more minds to think and hands to create have made new cities, more resources, more things, and seem to have given rise to healthier and wealthier societies.

Yet despite this evidence, the population scaremongers always draw exactly the opposite conclusion. Never has there been a political movement that has got things so spectacularly wrong time and time again yet which keeps on rearing its ugly head and saying: ‘This time it’s definitely going to happen! This time overpopulation is definitely going to cause social and political breakdown!’

There is a reason Malthusians are always wrong. It isn’t because they’re stupid… well, it might be a little bit because they’re stupid. But more fundamentally it is because, while they present their views as fact-based and scientific, in reality they are driven by a deeply held misanthropy that continually overlooks mankind’s ability to overcome problems and create new worlds.

The language used to justify population scaremongering has changed dramatically over the centuries. In the time of Malthus in the eighteenth century the main concern was with the fecundity of poor people. In the early twentieth century there was a racial and eugenic streak to population-reduction arguments. Today they have adopted environmentalist language to justify their demands for population reduction.

The fact that the presentational arguments can change so fundamentally over time, while the core belief in ‘too many people’ remains the same, really shows that this is a prejudicial outlook in search of a social or scientific justification; it is prejudice looking around for the latest trendy ideas to clothe itself in. And that is why the population scaremongers have been wrong over and over again: because behind the new language they adopt every few decades, they are really driven by narrow-mindedness, by disdain for mankind’s breakthroughs, by wilful ignorance of humanity’s ability to shape its surroundings and its future.

The first mistake Malthusians always make is to underestimate how society can change to embrace more and more people. They make the schoolboy scientific error of imagining that population is the only variable, the only thing that grows and grows, while everything else – including society, progress and discovery – stays roughly the same. That is why Malthus was wrong: he thought an overpopulated planet would run out of food because he could not foresee how the industrial revolution would massively transform society and have an historic impact on how we produce and transport food and many other things. Population is not the only variable – mankind’s vision, growth, his ability to rethink and tackle problems: they are variables, too.

The second mistake Malthusians always make is to imagine that resources are fixed, finite things that will inevitably run out. They don’t recognise that what we consider to be a resource changes over time, depending on how advanced society is. That is why the Christian Tertullian was wrong in 200 AD when he said ‘the resources are scarcely adequate for us’. Because back then pretty much the only resources were animals, plants and various metals. Tertullian could not imagine that, in the future, the oceans, oil and uranium would become resources, too. The nature of resources changes as society changes – what we consider to be a resource today might not be one in the future, because other, better, more easily-exploited resources will hopefully be discovered or created. Today’s cult of the finite, the discussion of the planet as a larder of scarce resources that human beings are using up, really speaks to finite thinking, to a lack of future-oriented imagination.

And the third and main mistake Malthusians always make is to underestimate the genius of mankind. Population scaremongering springs from a fundamentally warped view of human beings as simply consumers, simply the users of resources, simply the destroyers of things, as a kind of ‘plague’ on poor Mother Nature, when in fact human beings are first and foremost producers, the discoverers and creators of resources, the makers of things and the makers of history. Malthusians insultingly refer to newborn babies as ‘another mouth to feed’, when in the real world another human being is another mind that can think, another pair of hands that can work, and another person who has needs and desires that ought to be met.

We don’t merely use up finite resources; we create infinite ideas and possibilities. The 6.7billion people on Earth have not raped and destroyed this planet, we have humanised it. And given half a chance – given a serious commitment to overcoming poverty and to pursuing progress – we would humanise it even further. Just as you wouldn’t listen to that guy who wears a placard saying ‘The End of the World is Nigh’ if he walked up to you and said ‘this time it really is nigh’, so you shouldn’t listen to the always-wrong Malthusians. Instead, join spiked in opposing the population panickers.

Brendan O’Neill is editor of spiked, where this article was first published. The above is an edited extract of a speech given at the Wellcome Collection in London on Thursday 12 November.

Also read:

Population debate section, Abortion Review

UK: New research on intimate violence makes headlines

A government advertising campaign is being launched to raise awareness of domestic violence in teenage relationships.

The adverts will target boys and girls aged 13 to 18, urging them not to use violence against their girlfriends, BBC News Online reports.

The £2m TV, radio, internet and poster campaign is part of a government strategy announced last year to reduce violence against women and girls. Home Secretary Alan Johnson said it was essential to change attitudes in order to stop abuse against females. He said:

‘We want to see young people in safe and happy relationships and this means tackling attitudes towards abuse at an early age, before patterns of violence can occur. We hope this campaign will help teenagers to recognise the signs of abuse and equip them with the knowledge and confidence to seek help, as well as understanding the consequences of being abusive or controlling in a relationship.’

The campaign follows research by the NSPCC, which suggested that a quarter of girls aged 13 to 17 had experienced physical violence from a boyfriend and a third had been pressured into sexual acts they did not want. The children’s charity said it was alarmed by the number of young people who viewed abuse in relationships as normal.

One version of the advert shows two teenagers lying on a bed watching television. When the girl gets a text message from a friend the boy dislikes he loses his temper, throwing her phone to the floor and grabbing her by the hair.  The advert’s director Shane Meadows said he wanted to highlight the problem of emotional violence, including verbal insults and controlling behaviour such as monitoring text messages.

‘It’s a message I fundamentally believe in, and it’s what most of my films have been about - finding another way of leading your life. It’s a very powerful and valuable lesson,’ he said.

Another survey, reported by BBC News Online on the same day, claimed that a majority of women believe some rape victims should take responsibility for what happened. Almost three quarters of the women who believed this said if a victim got into bed with the assailant before an attack they should accept some responsibility.

The survey of more than 1,000 people in London marked the 10th anniversary of the Havens service for rape victims. The online survey, titled Wake Up To Rape, polled 1,061 people aged 18 to 50, comprising 712 women and 349 men.

More than half of those of both sexes questioned said there were some circumstances when a rape victim should accept responsibility for an attack. The study found that women were less forgiving of the victim than men.

Of the women who believed some victims should take responsibility, 71% thought a person should accept responsibility when getting into bed with someone, compared with 57% of men.

Elizabeth Harrison from the Havens said there was never an excuse for forcing a woman to do something she did not want to.

‘Clearly, women are in a position where they need to take responsibility for themselves - but whatever you wear and whatever you do does not give somebody else the right to rape you. It’s important people take the time to actually look at what they are doing and make sure the person they are with is actually wanting to go ahead with what they are proposing.’

The survey also found more than one in 10 people were unsure whether they would report being raped to the police, and 2% said they would definitely not do so. The main reasons were being too embarrassed or ashamed (55%), wanting to forget it had happened (41%) and not wanting to go to court (38%).

Meanwhile, the survey suggested that many people are relaxed about their safety. Almost half of people have walked home via side streets on their own. One in five has been so drunk they have lost their memory, while one in five has got into a taxi without checking whether it is licensed.

When asked about their own experiences, more than a third of those polled said they had been in a situation where they could have been made to have sex against their will. Women are more likely to have been in this situation - 40% compared to 20%.  And one in five adults had been in a situation where they were made to have sex when they did not want to. This had happened to more women (23%) than men (20%).

The Home Office said it had introduced a number of measures to the service provided to rape victims, including new police and prosecutors’ guidance, monitoring of services and funding for support for rape victims. A spokeswoman said:

‘The government is determined to ensure that every victim has immediate access to the services and support they need so that more victims have the confidence to come forward and report these crimes and we can bring the perpetrators to justice.’

Teenage domestic violence tackled by advert campaign. BBC News Online, 15 February 2010

Teen girls abused by boyfriends warns NSPCC. Press release, 1 September 2009.

Women say some rape victims should take blame - survey. BBC News Online, 15 February 2010

Wake Up To Rape Research: Summary Report. Prepared by Opinion Matters, for The Havens (Sexual Assault Referral Centres). [.pdf]

Climate change - Calling planet birth

On 13 February, the UK Guardian published a lengthy article by Oliver Burkeman arguing that ‘family size has become the great unmentionable of the campaign for more environmentally friendly lifestyles’. 

Burkeman argues:

‘...In 1998, most people weren’t willing to consider any significant lifestyle changes for environmental reasons, let alone cutting back on kids. Much has changed since then, of course, both in terms of the consensus on the threat posed by climate change, and our willingness to make sacrifices in the face of it. But one thing has not: you still won’t hear any major environmental campaign group in Britain or the US arguing that, in addition to flying less and recycling more, middle-class westerners should be having fewer children to save the planet. Even commentators who warn of the evils of overpopulation, proudly trumpeting their willingness to raise controversial issues in defiance of “political correctness”, only rarely emphasise the notion that we – rather than those in the developing world – might consider doing less of the populating. For several thorny reasons, family size has become the great unmentionable of the campaign for more environmentally friendly lifestyles. And yet, in the end, it may be the only one that really counts.

‘Trying to understand the debate about population and the climate sometimes feels like peering into a kaleidoscope while drunk. Directly contradictory claims, that can’t both be true at the same time, are advanced as if they were facts. Weird allegiances are created: George Monbiot and American creationists, for example, are roughly equally contemptuous of organisations such as the Optimum Population Trust; supporters of reproductive rights find common cause with anti-abortionists. You come across nutty-sounding fringe groups like the Voluntary Human Extinction Movement, but then you phone its founder, Les Knight – he’s a supply teacher, based on America’s west coast, and can only talk during breaks between lessons – only to discover that he isn’t nutty at all, but in fact rather sane and self-deprecating. (He simply wants people to choose not to breed. “Eventually we’ll be extinct anyway, but it would be so much nicer if we phased ourselves out through natural attrition,” Knight told me affably. “You know – the way a company reduces its workforce without firing anyone.")

‘For all the confusion and sensitivities that ­surround the subject, though, the basic facts are clear. If you live in Britain or the US in 2010, there is nothing you can do to reduce your impact on the environment that even comes close to the effects of having one fewer child...’

Read on: Climate change: calling planet birth, by Oliver Burkeman. The Guardian, 13 February 2010

Also read:

Population debate section, Abortion Review

UK: Tory MPs’ abortion opinions

A significant number of Conservative candidates in winnable seats hold strong anti-abortion views, the Financial Times reports.

This raises the prospect of a fresh drive to cut the time limit from 24 to 20 weeks should David Cameron win this year’s general election, says the FT.

Senior MPs, shadow cabinet members and party officials believe that if all those required to secure a majority at the next election win their seats, the result would create a big enough bloc of votes to tighten the existing legislation, aided by votes from some anti-abortion Northern Irish, Labour and Liberal Democrat MPs.

One shadow cabinet member said: ‘We will, I am sure, have the votes we need to do it. It’s something lots of us feel very strongly about – including David [Cameron].’

This view is confirmed by surveys of Tory parliamentary candidates by ConservativeHome.com, combined with research by the FT. Abortion is a so-called ‘conscience’ issue on which MPs are free to vote as they wish without being expected to toe a party line.

Tory MPs’ and candidates’ opposition to abortion is not, however, the result of deep religious convictions, the FT reports. Rather, one party adviser described the anti-abortion sentiment within the party as being an aspect of “right-wing political correctness. They think it goes with the package: pro-nuclear power, pro-nuclear weapons, pro-army, pro-life.”

Nadine Dorries, a backbench Conservative MP who led the effort to cut the abortion time limit when the issue was last debated in the Commons in 2008, has announced she intends to put down a bill to amend the existing law. If the Tories were to gain a majority she expected it to enter the statute book.

‘I was always aware that the real opportunity for abortion law reform would arise with a Conservative government,’ she said. ‘I anticipate that if I lay down a private member’s bill to tighten before the House after the election, it will pass.’

But Dr Evan Harris, a prominent pro-choice Liberal Democrat MP for Oxford West and Abingdon, suggested that the pro-life outlook of some Tory candidates contrasted with the way Mr Cameron was seeking to present his party to the electorate.

‘Conservative candidates’ stance on the rights of women to have abortions . . . belies the spin that David Cameron leads a modern and socially liberal party,’ he said. ‘Scientists [with an interest in embryology] and women in Tory target seats need to make sure they know the views of their Conservative candidates.’

Tory candidates reveal anti-abortion views. Financial Times, 12 February 2010

Also read:

UK Abortion Law section, Abortion Review.

USA: Sepsis after attempted self-induced abortion

A case report in the Western Journal of Emergency Medicine raises some useful questions about the practice of self-induced abortion in parts of the developed world, where abortion is legal and generally available. 

The authors note:

‘While unsafe abortions have become rare in the United States, the practice persists. We present a 24-year-old female with a 21-week twin gestation who presented to the emergency department with complications of an attempted self-induced abortion. Her complicated clinical course included sepsis, chorioamnionitis, fetal demise, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy for complications of endomyometritis. We discuss unsafe abortions, risk factors, and the management of septic abortion. Prompt recognition by the emergency physician and aggressive management of septic abortion is critical to decreasing maternal morbidity and mortality.’

As Kelly Culwell, MD, MPH, of IPPF notes, this case report is interesting for a number of reasons. One is that it highlights the unusual character of such events in countries like the USA: ‘Of the approximately 20 million unsafe abortions that occur globally each year, all but half a million are estimated to occur in developing countries. [1] In countries like the United States, which liberalized its abortion law nationally in 1973, septic abortion cases after self-induced abortion are now rare enough to be presented as published case reports, as in this article.’ Although the woman suffered from serious complications and the consequent loss of her uterus and ovaries, because she received prompt treatment she did not die.

The case is also unusual, writes Culwell, because it appears in an academic journal about emergency medicine rather than a journal of reproductive health. ‘As clinical academic articles tend not to describe the social circumstances around the case, we don’t know what lead to this woman having attempted a self-induced abortion. Was she unable to find a safe abortion provider? Did she only discover she was pregnant after her first trimester and was then unable to find a provider who offered second trimester procedures? Was she unable to afford the cost of the procedure, which is not covered in US military facilities, like the site of this report? Did she fear the stigma of seeking abortion care and fear a service in a safe clinical setting would not be confidential?’ Without understanding the particular circumstances surrounding this woman’s self-induced abortion, it is difficult to draw general conclusions about why she undertook this course of action. 

However, as Culwell concludes: ‘What is clear is that even in a country with a less restrictive abortion law, there still exist obstacles that prevent women from obtaining high quality safe abortion care. And even when faced with obstacles – many of which are erected purposefully to limit women’s access to safe abortion – a woman who has decided that she cannot continue a pregnancy may resort to any means necessary in order to end that pregnancy, even if it means risking death.’ While events such as these should be recognised as rare, they nonetheless provide a useful counter to complacent assumptions that all women who need abortions can readily access them, particularly in later gestations.

[1] Sedgh G et al. (2007) Induced abortion: estimated rates and trends worldwide. Lancet (9595):1338-1345.

The Back Alley Revisited: Sepsis after Attempted Self-Induced Abortion. Saultes TA, Devita D, Heiner JD. Madigan Army Medical Center, Department of Medicine, Tacoma, WA, USA. Western Journal of Emergency Medicine. 2009 November; 10(4): 278–280.

Discussed in IPPF Abortion Abstract 212, 9 February 2010.

Abortion doctors: credit where it’s due

After forty years of legal abortion in Britain, the doctors’ contribution is at last being recognised as a part of mainstream healthcare. Commentary by Jennie Bristow, Editor, Abortion Review.

At the beginning of this year, the British Medical Journal (BMJ) revealed the ten individuals shortlisted for the BMJ Group Lifetime Achievement Award 2010, which will go to ‘the individual who has, over his or her working lifetime, made a unique and substantial contribution to improving health care, whether in clinical practice, health services, public health, health policy, medical education, or medical research’.

Dr Wendy Savage, obstetrician, gynaecologist, academic and campaigner, has been shortlisted for this award, in recognition of the her tireless work in improving reproductive healthcare, both for women who need abortions and those who give birth.

To see the work of an ‘abortion doctor’ being given due recognition as a part of mainstream healthcare should not come as a surprise. Abortion has been legal in Britain for over 40 years, and during that time millions of women have been helped by doctors prepared to perform and perfect the procedure. The same compassion and interest that motivates obstetricians’ and gynaecologists’ desire to make childbirth as safe and straightforward as possible, and to limit the pain and discomfort involved, has also motivated doctors involved in abortion care to minimise the complications of abortion.

The result is that, for women in Britain today, abortion is extremely safe and widely available. Abortion is accepted as a necessary part of healthcare, and is funded accordingly through the National Health Service.

But unlike childbirth, the practice of abortion remains controversial. Delivering babies, or providing fertility treatment, are medical procedures for which social recognition and personal satisfaction can be taken for granted. Yet while modern British society firmly accepts the need for abortion, it is accepted as a necessary endeavour rather than promoted as a glamorous or fulfilling career move. Just as no woman ever wants to have to have an abortion, no doctor ever actively wants to perform abortions: doctors do it because they recognise that it has to be done.

Outside of the world of abortion provision and reproductive choice advocacy, the levels of skill required and compassion demanded of these doctors is rarely acknowledged. As a generation of women has grown up secure in the knowledge that they have access to safe, legal abortion, maybe this situation is beginning to change. The horrific murder of the American abortion doctor Dr George Tiller in May 2009 led to countless testimonials from women about how much his work had helped them, and widespread recognition of the bravery demanded of those in the USA who are prepared to provide controversial, ‘late’ procedures.

In Britain, the sad death of Peter Diggory in November 2009 at the age of 85 gives us cause to reflect, with less shock but with equal respect, upon the extent to which the reproductive freedoms held by women today are due to the courageous and energetic work of the doctors, campaigners and parliamentarians who brought the 1967 Abortion Act into being. Diggory, alongside David Paintin, Malcolm Potts and others, was one of the doctors whose experience of treating women suffering from the consequences of unsafe, illegal abortions motivated him to play a key role in bringing about the social legislation that would save women from the physical and emotional costs both of bearing an unwanted child, and having unsafe abortions.

Without the passionate commitment of the medical professionals involved in reforming the law back in the 1960s, the situation facing women in Britain today would be very different. And without the continuing commitment and care shown by abortion doctors today, women would find themselves at continued risk of unsafe abortion or of having to carry an unwanted pregnancy to term.

It is politically important that abortion is legal and accepted, but for that to mean anything requires doctors who are prepared to carry out the procedure, and who continue to bring their medical experience to bear on the social and legal discussion. For their historic contribution as much as their current work, awards to abortion doctors are long overdue.

The BMJ Group Lifetime Achievement Award 2010 is judged by a BMJ readers’ online poll, and will be announced on 10 March 2010. To vote for Wendy Savage, visit the BMJ website, scroll down and click on the poll on the right hand side.

This article appears in the Winter 2010 print edition of Abortion Review. Download the print edition for free here.
______________________________________________________

ABORTION LAW REFORMERS: PIONEERS OF CHANGE

Peter Diggory is one of the doctors, campaigners and parliamentarians interviewed in the 2007 BPAS publication Abortion Law Reformers: Pioneers of Change.

This pamphlet presents frank interviews with many of the campaigners, doctors and parliamentarians who brought the 1967 Abortion Act into being, providing an inspiring sense of the spirit in which the Act was conceived and thoughtful reflections on how well the law has worked subsequently.

Download it for free here.

UK: Excitement surrounds new form of emergency contraception

Ulipristal acetate, a recently licensed type of EC, may offer women protection from pregnancy even when taken five days after sex.

Scottish researchers found that ulipristal acetate worked well after the three-day limit of the most commonly used drug, levonorgestrel, BBC News Online reports.

At present ulipristal - unlike levonorgestrel - is only available with a prescription.

Emergency contraception uses hormones to either prevent the release of an egg by the ovary in the hours after sex, or stop it implanting into the the womb. Levonorgestrel is available from pharmacies, either with a prescription, or sold directly to over-16s.

A study by specialists working for NHS Lothian, published in The Lancet, tested the effectiveness of levonorgestrel and ulipristal (which was licensed for use last year) using a sample of more than 1,600 women from the UK, Ireland and the USA.

A total of 2.6% of the levonorgestrel group became pregnant despite taking the drug, compared with 1.8% in the ulipristal group.

In a much smaller group of women who received emergency contraception more than three days after sex, there were no pregnancies among women who had taken ulipristal compared with three pregnancies among those taking levonorgestrel.

The levels of side effects were roughly the same in both two drugs.

However, researchers said that the newer drug cannot be sold ‘over-the-counter’ at pharmacies because it did not yet have the established safety record of levonorgestrel.

Ann Furedi, chief executive of BPAS, described the new type of drug as ‘exciting news’. She said:

‘It offers a longer time window for use than the traditional, emergency contraception pill. Different hormones are involved to the ones traditionally used in contraception, so it may be that these will prove to have other contraceptive uses in future.

‘However, accessibility is key to the uptake of any time-sensitive medication and since this pill is not currently available over-the-counter and is significantly more expensive to buy than the traditional “morning after pill”, it may be that many women who could benefit from it are not able to access it.’

Five-day limit for post-sex pill. BBC News Online, 29 January 2010

Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Prof Anna F Glasier MD, Sharon T Cameron MD, Paul M Fine MD, Susan JS Logan MD, William Casale MD, Jennifer Van Horn MD, Laszlo Sogor MD, Diana L Blithe PhD, Bruno Scherrer PhD, Henri Mathe MSc, Amelie Jaspart MSc, Andre Ulmann MD, Erin Gainer PhD. The Lancet, Early Online Publication, 29 January 2010

USA: George Tiller’s killer guilty of murder

A man who said he killed the Kansas abortion doctor to save the lives of unborn babies has been found guilty of first-degree murder.

Scott Roeder had pleaded not guilty to murder, arguing that he committed manslaughter to prevent a greater harm, BBC News Online reports. He shot George Tiller, one of few late-term abortion providers in Kansas, at his church in Wichita on 31 May, 2009.

Roeder, 51, faces life in jail with the possibility of parole after 25 years. He is due to be sentenced on 9 March. The jurors took only 37 minutes to find him guilty of first-degree murder.

He was also convicted of aggravated assault for pointing a gun at two church ushers after shooting Dr Tiller.

Roeder’s lawyers had hoped he would face a lesser charge of voluntary manslaughter. But Judge Warren Wilbert ruled that that charge could not be considered because abortion, including the late-term abortions conducted by Dr Tiller, 67, was legal in Kansas.

The judge also ruled out a second-degree murder conviction, which does not involve premeditation.

On Thursday, Roeder told the court in Wichita:

‘I did what I thought was needed to be done to protect the children. I shot him. If I didn’t do that, the babies were going to die the next day.’

Because Dr Tiller performed late abortions, he had been a target of anti-abortion activists for many years. His clinic was one of only three in the USA that offered abortions performed after 21 weeks. It was heavily fortified after a bomb attack in 1986. Dr Tiller also survived an attempt on his life in 1993.

US man found guilty of abortion doctor murder. BBC News Online, 29 January 2010

Also read:

USA: Controversy surrounds trial of man who killed Dr George Tiller. Abortion Review, 14 January 2010

Comment: One family’s tragedy, not a political indicator. By Jennie Bristow. Abortion Review, 2 June 2009

Ulipristal acetate versus levonorgestrel for emergency contraception

This study found that ulipristal acetate provides women and health-care providers with an effective alternative for emergency contraception that can be used up to 5 days after unprotected sexual intercourse. Published in The Lancet.

Background: Emergency contraception can prevent unintended pregnancies, but current methods are only effective if used as soon as possible after sexual intercourse and before ovulation. We compared the efficacy and safety of ulipristal acetate with levonorgestrel for emergency contraception.

Methods: Women with regular menstrual cycles who presented to a participating family planning clinic requesting emergency contraception within 5 days of unprotected sexual intercourse were eligible for enrolment in this randomised, multicentre, non-inferiority trial.

2221 women were randomly assigned to receive a single, supervised dose of 30 mg ulipristal acetate (n=1104) or 1·5 mg levonorgestrel (n=1117) orally. Allocation was by block randomisation stratified by centre and time from unprotected sexual intercourse to treatment, with allocation concealment by identical opaque boxes labelled with a unique treatment number. Participants were masked to treatment assignment whereas investigators were not. Follow-up was done 5—7 days after expected onset of next menses.

The primary endpoint was pregnancy rate in women who received emergency contraception within 72 h of unprotected sexual intercourse, with a non-inferiority margin of 1% point difference between groups (limit of 1·6 for odds ratio). Analysis was done on the efficacy-evaluable population, which excluded women lost to follow-up, those aged over 35 years, women with unknown follow-up pregnancy status, and those who had re-enrolled in the study.

Additionally, the researchers undertook a meta-analysis of their trial and an earlier study to assess the efficacy of ulipristal acetate compared with levonorgestrel. This trial is registered with ClinicalTrials.gov, number NCT00551616.

Findings: In the efficacy-evaluable population, 1696 women received emergency contraception within 72 h of sexual intercourse (ulipristal acetate, n=844; levonorgestrel, n=852). There were 15 pregnancies in the ulipristal acetate group (1·8%, 95% CI 1·0—3·0) and 22 in the levonorgestrel group (2·6%, 1·7—3·9; odds ratio [OR] 0·68, 95% CI 0·35—1·31).

In 203 women who received emergency contraception between 72 h and 120 h after sexual intercourse, there were three pregnancies, all of which were in the levonorgestrel group. The most frequent adverse event was headache (ulipristal acetate, 213 events [19·3%] in 1104 women; levonorgestrel, 211 events [18·9%] in 1117 women). Two serious adverse events were judged possibly related to use of emergency contraception; a case of dizziness in the ulipristal acetate group and a molar pregnancy in the levonorgestrel group.

In the meta-analysis (0—72 h), there were 22 (1·4%) pregnancies in 1617 women in the ulipristal acetate group and 35 (2·2%) in 1625 women in the levonorgestrel group (OR 0·58, 0·33—0·99; p=0·046).

Interpretation: Ulipristal acetate provides women and health-care providers with an effective alternative for emergency contraception that can be used up to 5 days after unprotected sexual intercourse.

Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Prof Anna F Glasier MD, Sharon T Cameron MD, Paul M Fine MD, Susan JS Logan MD, William Casale MD, Jennifer Van Horn MD, Laszlo Sogor MD, Diana L Blithe PhD, Bruno Scherrer PhD, Henri Mathe MSc, Amelie Jaspart MSc, Andre Ulmann MD, Erin Gainer PhD. The Lancet, Early Online Publication, 29 January 2010

Abortion jabberwocky: the need for better terminology

A lively critique of the misleading language used about abortion, published in the journal Contraception.

Grimes and Stuart note that ‘the contentious issue of abortion is riddled with jabberwocky…terminology that is contradictory, obsolete, ambiguous and misleading’.  Both the lay and professional literature uses obstetrical terms improperly, they argue, and suboptimal terminology is widespread in obstetrics - indeed, many traditional terms are ‘inaccurate, insensitive or stigmatising’. The examples they cite include ‘fetal wastage’, ‘incompetent cervix’, ‘blighted ovum’ and ‘pregnancy failure’.

Regarding abortion, some misuse of terms is ‘inadvertent’, while other misuse is ‘intentional’. The effect, argue Grimes and Stuart, is ‘confusion of the public and medical profession about the nature and scope of abortion practice’. In this commentary, they highlight a number of examples of ‘archaic or suboptimal abortion terminology’ - for example:

‘Late-term’ abortion: an oxymoron

Dr George Tiller was widely reported as having provided ‘late-term’ abortions, but this phrase presents a contradiction in terms. In obstetrics, ‘term’ modifies ‘infant’ and indicates 260 to 294 completed days of pregnancy. Hence, the phrase ‘late-term’ abortion would suggest a pregnancy late in this interval. By definition, abortions are not performed after viabilityand certainly not at term (37 to 42 weeks’ gestation). ‘Late’ is a vague but acceptable adjective for abortion, but ‘late-term’ is not.

The trouble with trimesters

The trimester concept stems from obstetrical mythology; dividing a pregnancy into three equal segments has no basis in embryology or science. Debate continues as to the definitions of the trimesters. Does one divide 40 weeks by three, divide 38 weeks by 3 or divide 38 weeks by 3 and add 2 weeks to start counting from last menses? The trimester threshold does not help with determining the upper gestational age limit for abortion, since viability occurs before the end of the second trimester, regardless of the definition used. Clinicians should use completed days or weeks of pregnancy, not trimesters, to describe the duration of pregnancy.

Ordinal vs. cardinal numbers

Interchangeable use of ordinal and cardinal weeks of gestation further muddles gestational age limits. Many clinicians are unaware of the difference between these two types of numbers. A cardinal number indicates quantity; examples are one, two, three, etc. An ordinal number depicts rank in a series: first, second, third, etc. Ordinal numbers are one higher than the corresponding cardinal numbers. A child 13 months old illustrates the difference: having passed her birthday, she is one (cardinal) year old, but she is in her second (ordinal) year of life.

This difference makes a difference. Ambiguous or contradictory use of ordinal numbers occurs in more than a third of published articles on abortion. An example is use of ordinal numbers in a title that do not correspond to the cardinal numbers in the text. This problem has practical importance when specifying upper gestational age limits for abortion. For example, the 20th week of pregnancy is not 20 weeks of pregnancy.

Other examples of confusing terminology provided by Grimes and Stuart include partial-birth abortion (’a cunning conflation’ ), termination of pregnancy (all pregnancies terminate, but not all abort’ ), and the preborn (adults are not “postborn” or “predead” persons).

Grimes and Stuart offer some preferred terms:

‘Abortion can be performed up to viability; thereafter, according to standard dictionaries, other terms should be used for uterine evacuation. “Late” is an acceptable descriptor for abortion; “late-term” is not. Gestational age should be expressed in completed cardinal days, weeks or months; ordinal numbers (and trimesters) should be avoided. “Intact D&E” should be used instead of the oxymoronic “partial-birth abortion” or the mysterious “D&X.”

‘“Induced” is the proper adjective for abortion, not “elective” or “therapeutic” ... Obsolete euphemisms for induced abortion, such as “termination of pregnancy,” “medical termination of pregnancy” and “voluntary interruption of pregnancy” should be retired. “Standard” or “traditional” D&E can be used to distinguish this operation from intact D&E. Finally, the occupant of the uterus during pregnancy is an embryo or fetus.’

In conclusion, the authors offer an argument as to why ‘words matter’:

‘For decades, imprecise, misleading and obsolete abortion terminology has hindered, not helped, the ongoing debate about abortion. Medically accurate, dispassionate terminology is especially important when emotions run high, as is customary with abortion. Words should precisely convey meaning and, simultaneously, preclude possible misinterpretation. Physicians and other health care providers should take the lead in using and promoting proper medical terms. Better terminology for abortion can help the ongoing debate remain both civil and informative.’

Abortion jabberwocky: the need for better terminology. By David A. Grimes and Gretchen Stuart. Contraception Volume 81, Issue 2, Pages 93-96 (February 2010)

Ireland: New calls for change in abortion law

The Human Rights Watch organisation has called on the Irish government to decriminalise abortion, and a new survey suggests that two-thirds of 18-34-year-olds believe abortion should be legal.

In a report titled A State of Isolation: Access to Abortion for Women in Ireland, Human Rights Watch accuses the government is accused of violating a long list of human rights in its treatment of abortion and related issues, including ‘health, information, privacy, freedom from cruel, inhuman and degrading treatment, life, equal protection under the law, and nondiscrimination’, the Irish Examiner reports.

Human Rights Watch says the actions of the Government in the face of the ‘need for abortion’ have been ‘erratic and divisive’, and it calls for a change to its restrictive abortion laws to meet its obligations under international law. The document urges the Government to take ‘immediate steps toward decriminalising all abortion for women living in Ireland’, and it criticises the government for doing ‘little to mitigate the effects of a condemnatory public discourse on abortion’.

The report was launched in Dublin on 28 January. It was criticised by the anti-abortion site LifeSiteNews.com. Austin Ruse of the Catholic Family and Human Rights Institute, said:

‘Ireland has repeatedly put the abortion question before its citizens and the right to life has repeatedly won. This hectoring of a sovereign state by abortion radicals has got to stop. Ireland has decided.’

The results of an Irish Examiner/Red C poll published on 21 January found that two-thirds of 18-34-year-olds believe abortion should be legalised in Ireland, and that 81% of men believe the morning after pill should be freely available.

The survey also found that almost one in four Irish women has had an unplanned pregnancy and that 10% of 18-34 year olds have been in a relationship where the woman had an abortion. An overwhelming majority want more information on abortion services and one in four women has taken the morning-after pill three times.

Abortion is illegal in Ireland except where there is a real and substantial risk to the life (as distinct from the health) of the mother. This includes a risk arising from a threat of suicide. Women can travel abroad to get an abortion and it is lawful to provide information about abortions abroad, subject to strict conditions. It is not legal to encourage or advocate an abortion in individual cases.

Rights body calls for legalised abortion. Irish Examiner, 28 January 2010

Human Rights Watch Twists Ireland’s Arm to Legalize Abortion. LifeSiteNews.com, 26 January 2010

Two-thirds want abortion legalised. Irish Herald, 21 January 2010

Thinking ethically about emergency contraception

An excellent article in the Journal of the Catholic Health Association of the United States by Ron Hamel, PhD, examines the controversy over the use of emergency contraception in Catholic hospitals for victims of sexual assault.

Noting that at the heart of this controversy is the question whether ‘medications used for emergency contraception have an abortifacient effect’, Hamel argues that ‘much hinges on accurately understanding how these hormonal medications work’. Good moral judgments, he states, depend in part on good facts. Unfortunately, in the case of emergency contraception (EC), good facts are not always present:  ‘In many instances, critics base their moral judgments on prevailing beliefs or assumptions about mechanisms of action that may be based on drug manufacturer labelling, or on outdated scientific literature, or on mere supposition’.

Hamel examines the science of hormonal EC - known in the USA as Plan B - and concludes from this that ‘the preponderance of scientific evidence strongly suggests that Plan B does not have an abortifacient effect’. From there he discusses the issue of moral certitude, as opposed to absolute certitude. The evidence stops short of providing absolute certitude that EC is not an abortifacient - but, he asks, ‘is absolute certitude needed?’

Hamel explains:

‘In the Catholic moral tradition, what is required of an agent when he or she makes a moral judgment is that he or she have moral certitude about the correctness of the action ... Moral certitude means that the agent has excluded all reasonable possibility of error. It stands between mere probability, where alternative opinions are equally plausible, and absolute certainty, where any theoretical possibility of error is not only excluded, but is impossible.’

In relation to the question of whether EC should be given to victims of sexual assualt, Hamel argues that the scientific evidence its mechanism of action, and the high probability that there is no fertilised egg present subsequent to the sexual assault [as ‘the incidence of a pregnancy after rape is between <1 percent and 5 percent'], the 'requisite moral certitude exists that a fertilised ovum would not be destroyed by the administration of Plan B'.

In conclusion, Hamel argues:

'The administration of emergency contraception to women who have been sexually assaulted is a matter of utmost seriousness since it touches on human life. It is also a matter of utmost seriousness because it touches on the well-being of women who have been subjected to one of the most heinous of crimes. Any decision about whether or not to permit the dispensing of emergency contraceptive medications in Catholic hospitals and about the protocols for their administration has profound consequences.

'Those who make such decisions, whether bishops, hospital executives, emergency room physicians, nurses or others, have a grave moral obligation to take seriously one of the first rules in making good ethical judgments, namely, to obtain adequate and accurate information about the matter at hand. To do any less is not only to shortchange the moral process, but also to risk significant harm to others. And once the best possible information is obtained, those making the decisions need to keep in mind that the use of emergency contraception for women who have been sexually assaulted is a matter about which moral certitude is sufficient. Given what is currently known about Plan B from scientific research, Catholic hospitals can respond with sensitivity, compassion and assistance to women who have been raped and are in need of care, while being confident that they are also remaining true to Catholicism’s fundamental commitment to respect for human life.'

Ron Hamel is senior director, ethics, Catholic Health Association of the United States.

This article is reproduced in full here.

USA: New rise in teenage pregnancy rate

After more than a decade of declining teenage pregnancy, the rate among girls ages 15 to 19 increased 3 percent from 2005 to 2006, the Guttmacher Institute has found.

This development is likely to intensify the debate over federal financing for abstinence-only sex education, the New York Times reports.

The teenage abortion rate also crept up for the first time in more than a decade, rising 1 percent from 2005 to 2006, according to an analysis by the Guttmacher Institute, which examined federal data on teenage sex, births and abortion, along with the institute’s own abortion statistics. While teenage pregnancy rates for whites remain far lower than for blacks and Hispanics, the pregnancy rates increased for all three groups.

As has been previously reported, births to young women ages 15 to 19 rose from 2005 to 2006, and again from 2006 to 2007. Since the teenage pregnancy rate is made up of births, abortions and miscarriages, it is likely that the teenage pregnancy rate rose from 2006 to 2007, as well, the New York Times suggests. But several experts said it was too soon to predict whether teenage pregnancy and birth rates would continue to rise, and revert to the record high levels of the 1980s and early 1990s.

While it is difficult to pinpoint precisely how different factors influence teenage sexual behaviour, some experts speculate that the rise in teenage pregnancy might be partly attributable to the $150 million a year of federal financing for sex education that emphasised abstinence until marriage, avoiding all mention of the possible benefits of contraception.

‘This new study makes it crystal clear that abstinence-only sex education for teenagers does not work,’ said Cecile Richards, the president of the Planned Parenthood Federation of America.

The Clinton administration began financing abstinence-only programmes as part of welfare reform, but such programmes got a large boost in the Bush administration, the New York Times reports. The Obama administration has moved away from abstinence-only programmes, creating a new teenage-pregnancy initiative in which most financing will go to programmes that have been shown to prevent pregnancy, with some experimental approaches. Meanwhile, there are continuing efforts to reinstate financing for abstinence-only education as part of the health-reform legislation.

Lawrence Finer, director of domestic research for the Guttmacher Institute, said there was evidence that adolescent use of contraceptives had plateaued, or declined, adding that it was ‘an interesting coincidence’ that this had happened just as the focus on abstinence-only education had left fewer students getting comprehensive sex education.

Advocates of abstinence-only education, however, had a different view.

‘While this recent uptick is certainly disconcerting, it would be disingenuous to try to ascribe it abstinence education or any other single factor,’ said Valerie Huber, executive director of the National Abstinence Education Association. ‘The overly sex-saturated culture certainly plays a part, with teen sex communicated almost as an expected rite of passage, without consequences, and that’s a dangerous message for young people, who tend to be risk-takers anyway.’

According to the Guttmacher analysis, the teenage pregnancy rate declined 41 percent from its peak, in 1990, when there were 116.9 pregnancies per 1,000 women aged 15 to 19, and 2005, when there were only 69.5 per 1,000. In 2006, the rate rose to 71.5 pregnancies for 1,000 women. Teenage birth and abortion rates also declined in that period, with births dropping 35 percent from 1991 to 2005 and teenage abortion declining 56 percent between its peak, in 1988, and 2005.

After Long Decline, Teenage Pregnancy Rate Rises. New York Times, 26 January 2010

FOLLOWING DECADE-LONG DECLINE, U.S. TEEN PREGNANCY RATE INCREASES AS BOTH BIRTHS AND ABORTIONS RISE. Guttmacher Institute, 26 January 2010

Abortion and mental health: Evaluating the evidence

An article in American Psychologist evaluates empirical research addressing the relationship between induced abortion and women’s mental health. 

Two issues were addressed: (a) the relative risks associated with abortion compared with the risks associated with its alternatives and (b) sources of variability in women’s responses following abortion. This article reflects and updates the report of the American Psychological Association Task Force on Mental Health and Abortion (2008).

Major methodological problems pervaded most of the research reviewed. The most rigorous studies indicated that within the United States, the relative risk of mental health problems among adult women who have a single, legal, first-trimester abortion of an unwanted pregnancy is no greater than the risk among women who deliver an unwanted pregnancy. Evidence did not support the claim that observed associations between abortion and mental health problems are caused by abortion per se as opposed to other preexisting and co-occurring risk factors. Most adult women who terminate a pregnancy do not experience mental health problems. Some women do, however. It is important that women’s varied experiences of abortion be recognized, validated, and understood.

Abortion and mental health: Evaluating the evidence. Major, Brenda; Appelbaum, Mark; Beckman, Linda; Dutton, Mary Ann; Russo, Nancy Felipe; West, Carolyn. American Psychologist. Vol 64(9), Dec 2009, 863-890.

‘The last abortionist’

John H Richardson meets Warren Hern, provider of late abortions in the USA.

’The young couple flew into Wichita bearing, in the lovely swell of the wife’s belly, a burden of grief. They came from a religious tradition where large families are celebrated and they wanted this baby, and it was very late in her pregnancy. But the doctors recommended abortion. They said that with her complications, there were only two men skilled enough to pull it off. One was George Tiller, a Wichita doctor who specialised in late abortions.

‘They arrived on Sunday, 31 May last year. As they drove to their hotel, a Holiday Inn just two blocks from the Reformation Lutheran Church, they saw television cameras. They wondered what was going on, a passing curiosity quickly forgotten. But when they got to their room, the phone was ringing. Her father was on the line. “There was some doctor who was shot who does abortions,” he said. They turned on CNN. Dr Tiller had just been killed, shot in the head as he passed out church leaflets.

‘Now there is only one doctor left...’

‘The last abortionist’ was published in the UK Observer on 24 January. Read it here.

Women’s opinions on the home management of early medical abortion in the UK

A study led by Patricia Lohr of BPAS has found that most women report a preference for going home after misoprostol administration in order to complete an early medical abortion.

This survey was undertaken to obtain the opinions of women in the UK about their home management of early medical abortion (EMA) with mifepristone and misoprostol. All eligible women undergoing EMA at any BPAS clinic during a 2-week period were invited to participate. Women were contacted by telephone 1 week after the EMA and a five item structured questionnaire was administered. One open-ended question gave women the opportunity to freely comment. Demographics and responses were tabulated using descriptive statistics. Mulitivariable logistic regression was used to assess the influence of demographic characteristics on responses.

Of 249 enrolled participants, 162 were successfully surveyed (a 65% response rate). Most respondents (86%) would rather go home to complete an EMA than remain in a clinical setting. 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. Women were less likely to prefer home management if they were Asian (OR 0.21, 95% CI 0.05–0.87) or had a gestational age >49 days (OR 0.26, 95% CI 0.10–0.71).

The authors concluded that home management of EMA is acceptable to most women in the UK who have experienced it and is, for many, preferable to a clinical setting. Consideration should be given to updating the interpretation of the UK’s 1967 Abortion Act to allow home administration of misoprostol.

Key message points

* Most women surveyed report a preference for going home after misoprostol administration in order to complete an early medical abortion at home.

* Most women surveyed would prefer to self-administer misoprostol at home as opposed to returning to a clinic for administration.

* Asian women and those with a gestational age >49 days are less likely to prefer home management, however these findings should be interpreted cautiously given the small sample size of this study.

Download the article in full here.

‘Women’s opinions on the home management of early medical abortion in the UK.’ By Patricia A Lohr, Josephine Wade, Laura Riley, Abigail Fitzgibbon, Ann Furedi. Journal of Family Planning and Reproductive Health Care 2010; 36(1): 21–25. E-mail:

USA: Renowned clinical psychologist dies

Henry P. David, whose research on the psychological effects of abortion was hugely influential, died on 31 December 2009 at the age of 86. 

The Washington Post reports:

In the late 1960s, Dr David became one of the first to study the psychological aftermath of abortion. He guided younger psychologists to do similar research, and their combined efforts helped alter the prevailing assumption among clinicians that abortion was a source of mental health problems in women.

Their work influenced the public debate. As opposition to abortion mounted in the 1980s, President Ronald Reagan asked Surgeon General C. Everett Koop to prepare a report on the psychological effects of abortion. Koop, a vocal anti-abortionist, was widely expected to denounce abortion as a risk to women’s mental health.

After surveying 250 studies, including those by Dr. David and scientists he had mentored, Koop refused to issue the report, citing inconclusive evidence. Koop later called the psychological harm caused by abortion “minuscule from a public health perspective.’’

Dr David was best known for his study on unwanted children, the result of a chance meeting at a late-1960s cocktail party in Prague. Dr. David, who was in Czechoslovakia for research, struck up a conversation with the head of the country’s public health service. She asked whether he would be willing to find out what had become of Czech children whose mothers had wanted abortions but could not get permission. Struck by the unusual scientific opportunity presented by the communist government’s penchant for detailed recordkeeping, he agreed.

With the help of two Czech colleagues, Dr. David tracked 220 children whose mothers had twice requested and been denied abortions. He compared them with 220 children whose parents had wanted them, matching each against a counterpart with similar socioeconomic background, birth order and parents’ marital status.

He reported that by age 35, the unwanted children were less likely to have graduated from high school and have satisfying relationships. And he showed that they were more likely to be jailed and experience addiction.

The study, presented at the annual convention of the American Psychological Association in 1989, resulted in the Czech government’s decision to more freely permit abortion. It also gave ammunition to American abortion rights advocates in their efforts to challenge state laws requiring parental consent for abortions.

Read the obituary in full here:

Henry David dies; psychologist studied abortion’s effects. Washington Post, 15 January 2010

USA: Healthcare reformers battle over abortion

Opponents and supporters of abortion rights agree on something, writes Tom Kisken in the Ventura County Star. Both sides say they could have predicted that federal funding of abortion would emerge as a dividing line in the fight for healthcare reform.

’I would have thought it was a miracle if it hadn’t,’ said Christine Lyon of Planned Parenthood for Ventura, Santa Barbara and San Luis Obispo counties. She contends the perpetually scalding issue is being thrown into the healthcare fire in efforts to kill reform proposals and limit access to abortions. ‘I think we’re experienced, politically savvy enough to know that when these opportunities present themselves, they’re not going to be overlooked’.

The Rev. Rob McCoy of Calvary Chapel Thousand Oaks also believes the issue was fated to be a roadblock but for a different reason. He said Americans who believe abortion is innately wrong are worried the government is trying to use healthcare bills to extend abortion rights and allow more funding. ‘The government doesn’t give back power, they take it,’ he said. ‘… This is a conscience issue, and it has every right to be in the debate.’

There were reports late on 15 January that Senate and House leaders were very close to agreement on several key healthcare reform issues involving cost and coverage but still had to resolve abortion differences. The dilemma revolves around how to balance current bans on using federal money for abortion, except for rape, incest or when a woman’s life is in jeopardy, with the ability of insurers to cover the procedures.

The US House of Representatives bill constructs a wall blocking any person receiving government insurance subsidies from buying plans that cover abortion. Advocates of abortion rights worry the measure will mean millions of low- and moderate-income Americans won’t have a choice because they won’t be able to afford an abortion.

The Senate proposal, negotiated in an effort to guarantee passage of the reform bill, allows health plans subsidised by the government to cover abortions, but they would be funded through private money. That means people in those plans would send in two premium checks — one for the part of their coverage subsidised by the government and the other for coverage of abortions. States could also decide on their own to prohibit the plans from covering abortions.

People on both sides of the abortion debate say they’re unsure exactly how the two-check rule would work, writes Kisken. Opponents of abortion rights worry the federal government would end up funding abortions.

Some people involved say the final bill won’t include either the Senate or House amendment but some modification. Many predict the language will be closer to the Senate proposal in order to protect the 60 votes needed to pass reform.

Like every other abortion fight, the debate is often cast as liberals against faith-driven conservatives. But, argues Kisken, it’s the Democrats who wrote both amendments and are now fighting to see who wins.

John Green, an Ohio professor who studies the intersection of politics and religion, said the divide has grown because of an increase of Catholic Democrats in Congress who oppose abortion rights.

‘If abortion was not an issue within the Democratic party, then the debate would be very different,’ added Susan Estrich, a professor of law and political science at USC. ‘I think the Democratic party is a bigger tent than some people realise and some people want.’

Read the full article here:

Abortion is divisive in reform of healthcare. By Tom Kisken. Ventura County Star, 15 January 2010

Also read:

Senate and House Health Reform Bills Change Abortion Status Quo: Changes in Conference Needed to Preserve Abortion Neutrality. By Jessica Arons. Center for American Progress, 14 January 2010

Catholic bishops too powerful? By Jon O’Brien, President, Catholics for Choice. Washington Post, 15 January 2010

Don’t Want to Pay for Abortion Coverage? I Don’t Want to Pay For (Fill In The Blank). By Amie Newman, Managing Editor, RH Reality Check, 15 January 2010

USA: Controversy surrounds trial of man who killed Dr George Tiller

A judge in Kansas has sparked uproar by permitting Scott Roeder to argue that he was justified in killing the abortion doctor. 

Scott Roeder, 51, an airport shuttle bus driver with a history of schizophrenia, admitted that he shot George Tiller in the head at the start of a church service in Wichita in May.

Roeder claimed that the killing was justified because Dr Tiller was one of only four doctors in America willing to perform late-term abortions, The Times (London) reports.

In court papers filed on 12 January defence lawyers said: ‘In the mind of Mr Roeder the victim presented a clear danger to unborn children.’

Roeder was due to go on trial on 11 January on a charge of premeditated first-degree murder, which carries a mandatory life sentence. But the case was thrown into disarray when the judge ruled that Roeder could argue that he killed Dr Tiller to save unborn children.

The decision opened the way for Roeder to claim that the shooting amounted to voluntary manslaughter, a crime that could bring a prison term of less than five years. Kansas law defines voluntary manslaughter as intentional killing committed ‘upon an unreasonable but honest belief that circumstances existed that justified deadly force’.

Abortion rights groups protested that the ruling could bring more violence against doctors. ‘We’re greatly concerned. A voluntary manslaughter verdict would be catastrophic. It’s like putting a target on the back of abortion providers,’ Eleanor Smeal, president of the Feminist Majority Foundation, said.

Radical anti-abortionists welcomed the chance for Roeder to state his case. The Rev Donald Spitz, a spokesman for the Army of God anti-abortion group, said: ‘Pro-lifers have been convicted unjustly for years in the court systems because they have not been allowed to state why they took their actions against abortion mills or against baby-killing abortionists.’

Judge Wilbert postponed jury selection in the trial until today to hear legal arguments on his decision. The prosecution said that there could be no question of involuntary manslaughter because there was no evidence that Dr Tiller posed an imminent threat at the time of the shooting.

‘The state encourages this court to not be the first to enable a defendant to justify premeditated murder because of an emotionally charged political belief,’ the prosecution wrote. ‘Taken to its logical extreme, this line of thinking would allow anyone to commit premeditated murder but only be guilty of manslaughter, simply because the victim holds a different set of moral and political beliefs.’

Mark Rudy, for the defence, said that there was an imminent threat, adding: ‘There was a state-licensed facility operating ... It assumedly had a schedule of pending abortion procedures.’

Scott Roeder tells court: I was justified in killing abortion doctor. The Times (London), 13 January 2010

Also read:

Commentary: One family’s tragedy, not a political indicator, by Jennie Bristow. Abortion Review, 2 June 2009

Wendy Savage up for for prestigious medical award

The obstetrician and gynaecologist who has campaigned vigorously for women’s healthcare and abortion rights has been shortlisted for the BMJ Group Lifetime Achievement Award 2010.

Professor Wendy Savage is an inspirational leader in women’s health. As an obstetrician and gynaecologist, a campaigner, and an academic, she has a lifetime of contributions and achievements in women centred care and continues to be a champion of women’s rights in childbirth and fertility.

Currently honorary visiting professor at Middlesex University, Professor Savage qualified in 1960 and was the first woman consultant to be appointed in obstetrics and gynaecology at The London Hospital.

She has held many posts during her career, including senior lecturer in obstetrics and gynaecology at the London Hospital Medical College and honorary consultant in obstetrics and gynaecology at the Royal London Hospital.

Various hospital and academic posts took Professor Savage around the world, and she has worked in the United States, Nigeria, Kenya, and New Zealand, where she set up an abortion service before the law was liberalised.

Professor Savage’s reputation grew after a high profile inquiry in 1985. After being accused of incompetence in the management of obstetric cases and suspended from her post at the London Hospital Medical College, she was cleared of all charges and reinstated in 1986.

She was an elected member of the General Medical Council for more than 16 years, serving on several committees. In addition to extensive clinical, teaching, and research experience in the UK she has written several books and published many papers.

Professor Savage has coordinated Doctors for a Woman’s Choice on Abortion for many years and supported women’s right to safe, legal abortion in the UK.

She is a longstanding member and former president of the Medical Women’s Federation. A former member of the Council of the BMA, she remains an active member.

The BMJ Group Lifetime Achievement Award 2010 will go to ‘the individual who has, over his or her working lifetime, made a unique and substantial contribution to improving health care, whether in clinical practice, health services, public health, health policy, medical education, or medical research’. The award is judged by a BMJ readers’ online poll - voting is open to all, from 4 January to 12 February. 

Ann Furedi, chief executive of BPAS, said:

‘Wendy has fought for women’s right to decide how their pregnancies ended whether in childbirth or abortion. She put her reputation on the line in defence of women’s choice many years before it was fashionable, or even acceptable. She’s a true reproductive health hero and we owe her a great debt of gratitude.’

To vote for Wendy Savage, visit the BMJ website, scroll down and click on the poll on the right hand side.

News: BMJ Group Lifetime Achievement Award - Professor Wendy Savage. British Medical Journal, 29 December 2009

Also read:

Stop doctoring the statistics! By Wendy Savage. Abortion Review, 2 June 2008

UK: Obituaries for Peter Diggory

Malcolm Potts, writing in the Guardian, pays his respects to this pioneering obstetrician/gynaecologist. Dilys Cossey adds a personal note.

Peter Diggory, who has died aged 85, was a talented and concerned obstetrician/gynaecologist who served generations of women at the Kingston hospital, Surrey, and the Royal Marsden hospital in London. In his quest for modern family planning and safe abortion he also helped establish policies and practices that helped millions of women around the world who would never know his name, but for whom he had helped open a door on the fundamental right to decide whether, and when, to have a child.

Diggory was born in Titley, Herefordshire, the son of a stationmaster and the youngest of five children. He won a scholarship to Worcester Royal grammar school and earned his first graduate degree, in mathematics, from University College London. After graduating he was drafted to join a team of young researchers developing radar. At the end of the second world war he returned to UCL for a second degree, in medicine. Diggory was elected president of the British Medical Student Association, played chess for the university, and began his postgraduate training, first becoming a fellow of the Royal College of Surgeons and then of the Royal College of Obstetricians and Gynaecologists.

In the 1960s, criminal abortion cases were not routinely admitted to the Queen Charlotte’s hospital, where Diggory trained, and doctors were not examined on contraception or abortion. When he was appointed the NHS consultant gynaecologist at Kingston hospital in 1961 he found himself ill-prepared to care for the 400 women admitted annually because of complications resulting from illegal abortions. Under a law dating from 1861, even the intention to perform an abortion was a felony, and so this huge area of reproductive health was simply ignored.

From 1938 the legal precedent set by the Bourne case enabled doctors to terminate the unintended pregnancies of women whose mental health could be shown to be at risk; in practice this applied only to those who could afford to pay a psychiatrist as well as a gynaecologist, and abortion remained outside mainstream medicine. Diggory had a Harley Street practice beside his NHS work and he alone had the integrity to publish his clinical findings. In a landmark paper on 1,000 cases, published in the Lancet, he showed that abortion could be clinically and emotionally safe.

While the president and the majority of the Royal College of Obstetricians and Gynaecologists fellows opposed reforming the 1861 law, Peter had the courage to join the Abortion Law Reform Association. I still remember his stunning speech at the 1966 Family Planning Association Conference on Abortion in Britain. It was the first time an experienced gynaecologist had talked openly about abortion. He compared the rich women getting safe private operations with the poor women admitted to an NHS hospital whose neighbours had injected soap, whisky or even toothpaste into the uterus.

A few months later, the young Liberal MP David (now Lord) Steel introduced a private member’s bill to reform the 1861 law. Diggory co-piloted this revolutionary step, attending every committee discussion for the next 17 months. His clinical experience had taught him that most abortions are for social reasons, and he worked closely with Steel to ensure social indications for abortions were included in the new law.

British abortion reform had a domino effect in India, Singapore, Zambia, Australia and the US, giving Diggory’s leadership in contraception and safe abortion an international impact. He attended international meetings and published widely, including co-authoring two books, Abortion (1977) and Textbook of Contraceptive Practice (1983).

Diggory’s life was characterised by an unalloyed kindness and generosity. He married Patricia McConnell in 1952. They shared an interest in the theatre, especially the fringe, and were trustees of the children’s theatre company Quicksilver. In addition to their two children, Paul and Jane, Peter and Patricia had an extended family of close younger friends. Even vagrants knew that the Diggorys’ house in Campden Hill Square, west London, would supply food and help. The same gentle warmth that drove Diggory to champion safe abortion also made him support the Voluntary Euthanasia Society. Poignantly, his last years were burdened with diabetes and vascular dementia – but even when he could not remember what he had had for breakfast, he could still play an excellent game of chess. Patricia died in 2002. Peter is survived by Paul and Jane.

• Peter Lionel Carr Diggory, obstetrician and gynaecologist, born 6 January 1924; died 22 November 2009

This obituary was published in the Guardian: Gynaecologist at the forefront of abortion reform, by Malcolm Potts, 4 January 2010

Dilys Cossey, secretary of the Abortion Law Reform Association (ALRA) 1964-68, writes:

Malcolm’s obituary of Peter Diggory captures the man perfectly – his intellectual ability, his warmth and generosity and his professional and personal commitment to abolishing the scourge of illegal abortion and giving women reproductive choice. 

Malcolm’s words about Peter are a reminder of the strong personalities of the 1960s abortion law reformers – the ‘pioneers of change’, as the BPAS publication issued to commemorate the 40th anniversary of the 1967 Abortion Act calls them – and of their dedication to the campaign to change the law. 

In his contribution to Pioneers of Change, Peter describes his original, ground-breaking research at Kingston Hospital, to which Malcolm refers.  Of specific relevance today is Peter’s comment: ‘The Abortion Act was a highly successful piece of social legislation… It is easy to take its benefits for granted since medical students and doctors no longer see cases of criminal abortion and it is hard for them to realise what a degrading and dangerous thing it used to be’. 

His concluding sentence reads: ‘Personally I remain grateful that ALRA and David Steel allowed me to help change our law’.  We should all remain grateful to Peter Diggory.

Peter Diggory was interviewed for the 2007 BPAS publication Abortion Law Reformers: Pioneers of Change. These frank interviews with many of the campaigners, doctors and parliamentarians who brought the 1967 Abortion Act into being provide an inspiring sense of the spirit in which the Act was conceived and thoughtful reflections on how well the law has worked subsequently. Download it for free here.

USA: Senate passes healthcare reform bill

President Obama’s signature policy reaches the next stage.

The bill aims to cover 31m uninsured Americans and could lead to the biggest change in US healthcare in decades, BBC News Online reports. President Barack Obama welcomed it as offering ‘real and meaningful’ reform, saying it was the most important piece of social legislation since the 1930s.

However, the bill must still be reconciled with more expansive legislation passed by the House of Representatives. The process of reconciling the two bills is expected to begin in January and will require further tough negotiations. Once that has been done, Mr Obama will be able to sign the measure into law.

The Senate bill was adopted by 60 votes to 39, with senators voting along party lines. Fifty-eight Democrats and two independents backed the legislation, while Republicans voted unanimously against it.

Healthcare reform has dominated American politics all year. Even many of the presidents’ own Democratic party were unsure about the bill, its cost and its implications. The bill’s passage in an early morning vote on Christmas Eve follows months of political wrangling and 24 days of debate in the Senate chamber. Opposition Republicans say the legislation is expensive, authoritarian and a threat to civil liberties and accuse the Democrats of rushing it through.

Under the Senate bill, most Americans would have to have health insurance. Private insurers would be banned from refusing to provide insurance because applicants had pre-existing medical conditions. The House version, passed in November, still includes a public option and also differs on how to pay for the reform.

Under the House version of the bill, health care plans could choose whether to cover abortion, but the public plan would not provide abortion coverage. The Senate version sets limits on the use of public money for abortion services.

US healthcare bills: House v Senate. BBC News Online, 24 December 2009

US Senate passes landmark healthcare reform bill. BBC News Online, 24 December 2009

‘After the hype, Copenhagen provides cold reminder of political reality’

Leo Bryant, Advocacy Manager for Marie Stopes International, blogs about his experience of discussing family planning at the Copenhagen climate change conference. 

Bryant writes:

COPENHAGEN, Denmark — My experience of the conference against global warming had an aptly chilly start — seven hours of queuing outdoors in the Danish winter. To my surprise, informing the guards that I had to give a scheduled presentation on the integration of rights-based family planning into climate change adaptation efforts yielded neither fast-track entry nor sympathy. COP15 had accredited over 40,000 delegates to attend a conference venue with a capacity for 15,000 and the consequences were dire. A huddled line of NGO workers, journalists, academics and civil servants stretched over a kilometre, waiting for hours in sub-zero temperatures in a queue that didn’t move – with incredible good nature – to participate in the conference that they hoped would save the world. If this conference was any indication of COP15’s ability for organisation, the world’s prospects were looking very bleak.

After more than six hours without food or water in intermittent snow, I was finally allowed entrance to the official registration hall. Although I had missed my presentation by several hours, queuing in the warmth now felt like relative luxury. And I have never felt so grateful for a cup of tea in my life. I eventually received my registration pass and, while saddened and angered to have missed the opportunity to discuss the ecological relevance of family planning with other NGO reps, I still had a session to look forward to tomorrow with Members of Parliament (MPs) from around the world.

The next day, entrance passed more smoothly for me (although this was not the case for many others and some were talking of seeking legal redress with the UN). At a lunchtime talk arranged by a Danish sexual reproductive health and rights organisation Sex&Samfund, I had a chance to address almost fifty MPs on how rights-based family planning programmes can make a difference in meeting the ecological challenges faced by countries worst affected by climate change.

I read from an official adaptation strategy document of the Rwandan government. “Adaptation” refers to efforts designed to help countries to cope with worsening climatic conditions, as contrasted with “mitigation” efforts to reduce carbon emissions. The document explained how rapid population growth in Rwanda – which has a contraceptive prevalence rate around 10% – is causing soil erosion as agrarian land use in high population density areas intensifies. The identified consequences include declining agricultural production, landslides and migration to less hospitable areas that are increasingly prone to flood and drought due to extreme weather.

After referencing a few examples of how rapid population growth is exacerbating the challenges of climate change – such as in Bangladesh where rising sea levels are contaminating fresh water sources with salt even as a growing population demands ever more drinking water – I returned to my seat. Attempts to discuss the macro-level consequences of the ongoing failure to ensure universal access to family planning can often be met with hostility, so I was anxious to learn how the MPs around my lunch table would react to the suggestion that slower population growth rates could assist in adapting to environmental challenges.

A veteran MP from Guatemala spoke first. “You spoke well,” he said with a kind but dismissive wave of the hand. “We agree with the need for family planning. But there are those who say that we must use it to reduce our carbon emissions. There are more than thirty vectors and pathogens in Guatemala being found at higher and higher altitudes because of warmer temperatures. Soon nowhere in Guatemala will be safe from these diseases and it is the indigenous people in the mountains who will die. Why? Because in Europe and America they pollute. And they tell us we must reduce our carbon. I ask you, where is the justice?” His age prevented him from shouting his last four words but he shook with emotion when he spoke them. I considered an argument I had seen recently in the papers – that family planning could reduce Guatemala’s carbon emissions by limiting the number of Guatemalans – and just how offensive it seemed at this point. His invocation of moral justice felt frankly unassailable.

Fortunately, an MP from Bangladesh came to my rescue. “In Bangladesh we believe family planning is very important,” he began. “We have very high population density and not enough land or natural resources. We do not want the density to increase as it will be more difficult when the glaciers in the Himalayas melt and we lose rivers. We want family planning everywhere and we want development programmes and resources to adapt. For this we need your support.” I was relieved the conversation had returned from carbon emissions to adaptation but was also keen to avoid the role I appeared to be heading for of representing Western donor interests.

“I work for Marie Stopes International” I told them, “and we would like to assist in countries struggling to adapt to climate change but there is little recognition that family planning has anything to contribute. What would you suggest we do?” I hoped that this might turn the conversation towards the means of integrating family planning into environmental sustainability and land management programmes. The MP from Bangladesh read my mind: “We don’t want family planning to be counted as an adaptation strategy” he said. “Yes it would help with the demand for natural resources but that is not the point. Donors would just say that the money they already give for family planning counts as adaptation support and then leave it at that. We need more resources for adaptation and for family planning.” Thus, my carefully crafted advocacy strategy was undone by a dose of political reality from the South.

Back in my hotel room reflecting on what I had learned, the cold logic of the argument for using family planning to reduce carbon emissions remained hard to refute, but it clearly raised moral questions and what’s more had no traction amongst the politicians I had met from the South. On the other hand, the argument for using improved access to family planning services to help adaptation to local environmental challenges (which I had thought was quite novel) seemed already an accepted concept, a t least in Bangladesh and several other countries. But a tired cynicism for the way bilateral donors are perceived to avoid genuine, overall increases in financial support was obstructing innovation for a multi-sector approach to supporting communities better cope with their local environment. People in the world’s poorest countries are under no illusion about who is responsible for their worsening climatic conditions. Unless, post-Copenhagen, donors find new commitment to genuine increases in ODA that reaches both environmental management and family planning, innovative programmes integrating reproductive health, women’s empowerment and environmental sustainability are unlikely to become a large-scale reality.

After the hype, Copenhagen provides cold reminder of political reality, by Leo Bryant. MSI, 21 December 2009

Also read:

Population debate section, Abortion Review

Abortion, mental health, and the limits of science

The debate about whether abortion causes depression should not be left to medical experts to resolve. Commentary by Jennie Bristow.

A recent commentary published in the journal Contraception by Julia Steinberg and Nancy Russo argues that guidelines should be developed ‘for others to follow when evaluating research on abortion and mental health’. (1)

Their argument is that shoddy studies continue to be published in peer-reviewed journals appearing to show an association between induced abortion and mental illness, despite the fact that two major reviews of the literature – one by the American Psychological Association (APA) (2) – have identified the weaknesses in studies purporting to find such an association.

Guidance on good research is needed, suggest Steinberg and Russo, because ‘studies of abortion and mental health require researchers to make study design and data analyses choices’, and these may ‘create bias towards or against a specific, directional claim’. In lay terms, this means that scientific studies that claim to show an association between abortion and mental ill-health can be politically motivated, and designed in such a way that they will find ‘evidence’ to support the a priori claim that abortion is damaging to women’s health. This is not sound science, but a particular moral or political claim masquerading as science.

Steinberg and Russo suggest that formalising guidelines about how to evaluate studies on the controversial question of whether abortion leads to negative mental health outcomes ‘will improve the quality of future research and the debate around clinical and regulatory measures proposed in response to the existing body of research’.

Separating politics from science

Those familiar with the debate about abortion and mental health will sympathise with Steinberg and Russo’s frustrations with the publication of biased studies. The attempt to present moral arguments against abortion in the form of scientific ‘evidence’ about the health problems they allegedly cause for women has been a long-running strategy of the anti-abortion movement, and as such represents a cowardly and dishonest attempt to scare people around to its point of view.

Over the years, Russo and her colleagues have invested a significant amount of time and energy in examining the research about abortion and mental health, and evaluating it in a rigorous and nuanced way. The balanced character of the debate about this question to date is testament to their work. But can the question of whether abortion is associated with mental illness be resolved within the domain of scientific studies? Is it right to expect that resolving this debate should be the sole responsibility of those few individuals who have expertise in dealing with the evidence?

The first problem is that the ‘abortion and mental health’ issue is not simply a scientific or medical question, but a moral and political one. In her 2003 critique Abortion, Motherhood and Mental Health, the sociologist Ellie Lee examines the history of the anti-abortion movement’s attempts to present its claims in scientific terms, by trying to prove the existence of a specific ‘Post-Abortion Syndrome’. (3) In this way, argues Lee, claims that were previously ‘moralised’ have become ‘medicalised’. As moral claims have failed to win the arguments, medical claims are used in a way that attempts to shut down debate about the rights and wrongs of abortion, with the arguments recycled as a ‘woman-centred’ claim that abortion damages women’s health. 

The politicised character of much research purporting to show that abortion causes mental health problems is damaging both to the debate about abortion, and to the integrity of science. But there is a limit to the extent to which ‘better science’, as proposed by Steinberg and Russo, can address this broader problem of politicisation.

Sound science is always a worthwhile goal, and there are precedents when it comes to establishing methodological guidelines for research. Steinberg and Russo are not suggesting that there is one ‘right answer’ to whether abortion is associated with mental health problems in some women. As the APA review states:

‘Well-designed, rigorously conducted scientific research would help disentangle confounding factors and establish relative risks of abortion compared to its alternatives, as well as factors associated with variation among women in their responses following abortion. Even so, there is unlikely to be a single definitive research study that will determine the mental health implications of abortion “once and for all” given the diversity and complexity of women and their circumstances.’

But even if it were proved beyond a shadow of a doubt that abortion was not associated with mental illness in any women at all, this would not stop the anti-abortion lobby from claiming that it did, or researchers from trying to find contradictory evidence. In this politicised context, there is a danger that attempting to regulate for better science could be interpreted as an attempt to restrict debate or alternative perspectives on the question.

The 2008 APA review, and to a lesser extent to 2004 evidence-based guideline on induced abortion produced by Britain’s Royal College of Obstetricians and Gynaecologists (4), have shown that the medical establishment is generally capable of weighing up the evidence that exists about abortion and mental illness, and making a judgement as to its worth. This is important, as it indicates that shoddy studies are not inevitably taken at face value.

However, the more important point is that abortion rights, provision and women’s experience are not questions that can or should be resolved through a narrow examination of how abortion impacts upon women’s mental health. If the issue of how we deal with research around this question becomes pigeon-holed as an area on which non-experts have no contribution to make and for which they have no responsibility, this not only puts an unfair burden onto experts such as Nancy Russo. It also absolves others in the pro-choice movement from engaging with this question in relation to broader insights about women’s experience and the role of abortion policy.

Confusing sadness with mental illness

Part of the reason why there has been an explosion of biased research into the association between abortion and mental illness is because of a wider interest with mental health in general, and the way that mental illness itself has become expanded as a concept and politicised by claims-makers.

It is now routinely argued that there is a direct relationship between difficult life events, such as losing one’s job, moving house or studying for exams, and depression. This leads to attempts to manage the issues within a medical framework: such as in the recent initiative by the UK government to provide a form of therapy for those unemployed as a consequence of the recession. (5)

The glib assumption that life difficulties lead directly to mental illness is a problem on two main fronts. Firstly, it simplifies this extremely complex field, and thereby acts as a barrier to understanding specific cases of mental illness, diverting expertise and resources away from those who need them. Secondly, it contributes to a brittle and one-sided understanding of normal human emotion, which implies that happiness is the emotional norm and all deviations from this should be pathologised as illness.

The expansion of mental illness is a key feature of Ellie Lee’s critique, where she examines this trend specifically in relation to reproductive events – abortion and childbirth. Clearly, both such life events are significant for women, and may involve a range of emotional reactions: it would be facile to think that either abortion or childbirth could be considered free from any psychological cost. But because emotional reactions are now problematised within the framework of mental health and illness, both abortion and childbirth tend to be discussed outside of the context of women’s lives, and pitted against one another in the narrow terms of which is most likely to make women ill.

Lee illustrates this with the example of the increasing diagnoses of Post-Natal Depression amongst mothers who experience negative emotions following the birth of their babies. While a proportion of new mothers may experience severe clinical depression, which requires psychiatric treatment and management, the experience of this group has tended to be collapsed together with the experience of those new mothers feeling tired, anxious and unhappy following the birth of their babies, but whose emotional state will recover with time.

In this context, the label of Post-Natal Depression risks pathologising a range of normal, negative emotions and the women who exhibit them, implying that women who give birth ‘should’ be feeling happy and relaxed, and those who do not should be labelled mentally ill. This diverts attention and resources away from the minority of women suffering from severe mental health problems, and risks making mothers generally defensive about their emotional state. It has also meant, as Lee shows, that arguments about the mental health cost of abortion have been limited by concerns about the (arguably greater) mental health costs of childbirth.

Examining the claims and counter-claims about abortion and childbirth made in this way, one has to ask: where does this leave women? Unless it is to be argued that women should avoid pregnancy and childbirth altogether because the psychological cost of both is too high, discussion and policy has to recognise that women will have abortions and babies regardless of whether it makes them happy or sad at the time – and that women who have negative experiences of abortion or childbirth may nonetheless go on to have another abortion, or another baby, because that it what is right for them in the long term.

In this case, an attempt to regulate women’s emotions according to how they ‘should’ be feeling is profoundly unhelpful. Most would agree that it is unreasonable to expect that a woman who has had an abortion will be ‘happy’ as a result – abortion is not a choice women make to improve their lives, but a resolution to the unexpected problem of unintended or unwanted pregnancy; the least bad option in the circumstances.

If the negative emotions that may follow this event are pathologised as markers for mental illness rather than accepted as normal and understandable reactions, this de-contextualises women’s experiences and dehumanises their emotional reactions. The question should not be whether a woman feels happy or sad immediately following an abortion, because all women may feel differently and there is no ‘right’ way of feeling. Rather, the question should be: was that decision the best one for her to make in terms of the rest of her life?

Women’s decision-making

In this regard, it is worth looking at a recent study led by David Fergusson of Christchurch, New Zealand. Fergusson and colleagues have conducted a set of studies examining abortion and mental illness, and this work is often received by the mainstream press as further evidence to back up the anti-abortion cause: as indicated by this recent headline, from the UK Daily Telegraph: ‘Abortion can put women at increased risk of mental health problems, says study’. (6) But while Fergusson’s work does find an association between abortion and mental illness, its findings are more subtle and interesting than the mainstream headlines would imply.

The most recent study, on ‘Reactions to abortion and subsequent mental health’, is published in the British Journal of Psychiatry. (7) Fergusson et al found that women who have abortions report high rates of both positive and negative emotional reactions. Those women reporting negative reactions ‘had rates of mental health disorders that were approximately 1.4 to 1.8 times higher than those not having an abortion’.

There are a number of limitations to this study, which the authors recognise, and to this extent the findings need some interrogation. Certainly, understanding the precise relationship between abortion and mental illness that is found by this study may well be beyond the scope of those who lack expertise in the field of mental health. But many of the study’s other findings are easily understandable, and worthy of consideration by those who are simply familiar with women’s experiences following abortion and committed to the pro-choice perspective.

For example, 90 per cent of women stated that their abortion was ‘definitely the right decision’, and only two per cent said it was ‘definitely the wrong decision’. This indicates that women are capable of taking hard decisions that might make them unhappy at the time, but with the recognition that this will be the best thing for them ultimately.

Where the authors found an increase in mental health problems among women who had had abortions, these were women who had reported high levels of distress. When taken with the finding that the vast majority of women believed abortion was the right option for them, this in no way indicates that abortion makes all women ill, or that women’s access to abortion should be restricted. Rather, it supports what those working in reproductive healthcare already know: that women seeking abortions should be treated with kindness and sympathy, that abortion should be provided within a culture that does not treat is as something that is morally bad, and that women should make, and be sure about, their own decision to have an abortion.

It is also worth noting in this context that it should not be assumed that all women will experience abortion as an emotionally difficult event: some may simply see it as the pragmatic response to a problem, and be simply relieved when it is over. In these cases, ‘too much’ sympathy or counselling could cause problems of its own, in encouraging women to feel that they should be more upset than they are and thereby increasing their levels of distress. As with all difficult life events, individuals’ circumstances and reactions are different, and sensitive care will focus resources on those who have particular needs or experience greater difficulties.

Furthermore, the study’s conclusion – that there is no evidence that abortion reduces mental health risks, and that this raises important questions about ‘the practice of justifying termination of pregnancy on the grounds that this procedure will reduce risks of mental health problems in women having an unwanted pregnancy’ – is not one with which those committed to the pro-choice perspective would necessarily disagree. As was argued in the 2008 British debate about the abortion law, it would be far better to have a law that allows for women to have abortions on request, rather than forcing both women and doctors to engage in a pretence that the discussion is about their mental health.

The need for a wider debate

Whatever their motivations, researchers will continue to examine the question of abortion and mental health, and the medical establishment will continue to argue it out. But the question of whether women should be permitted or denied access to abortion is a moral and political one, which will never be resolved in the domain of science. If this debate is put aside for ‘the experts’ to sort out according to evidence alone, pro-choice advocates will be avoiding their own responsibility for creating a culture in which the perceived rights and wrongs of abortion can be argued out openly and honestly.

Meanwhile, the question of how women experience abortion will be affected by their personal circumstances and the culture in which they live, and these experiences should be recognised and examined for what they are: not as narrow markers for better or worse mental health, but emotional reactions that should be taken into account as a standard part of sensitive abortion care. It does women no favours to imply that abortion will make them depressed, or that it will have no emotional impact upon them whatsoever. What matters is that they are recognised as being capable of making these decisions, and weighing them up within the context of their own lives.

Jennie Bristow is editor of Abortion Review. Email

(1) Evaluating research on abortion and mental health. Julia R. Steinberg, Nancy Felipe Russo. Contraception, Volume 80, Issue 6, Pages 500-503 (December 2009)

(2) Report of the APA Task Force on Mental Health and Abortion. American Psychological Association, 13 August 2008

(3) Abortion, Motherhood and Mental Health: Medicalizing reproduction in the United States and Great Britain. By Ellie Lee. Aldine Transaction 2003. Buy this book from Amazon (UK).

(4) The Care of Women Requesting Induced Abortion. Royal College of Obstetricians and Gynaecologists, 2004.

(5) Jobless to be offered ‘talking treatment’ to help put Britain back to work. Guardian, 4 December 2009

(6) Abortion can put women at increased risk of mental health problems, says study. Daily Telegraph, 2 November 2009

(7) Reactions to abortion and subsequent mental health. David M. Fergusson, PhD, L. John Horwood, MSc and Joseph M. Boden, PhD The British Journal of Psychiatry (2009) 195: 420-426. doi: 10.1192/bjp.bp.109.066068

Also read:

Debating abortion in a therapy culture. By Ellie Lee. Abortion Review, 14 October 2008

A depressingly narrow debate. By Jennie Bristow. Abortion Review, 5 December 2008

Spain: Abortion bill progresses

Lawmakers voted to ease Spain’s abortion law on 17 December, approving a bill to allow the procedure without restrictions up to 14 weeks, AP reports.

The measure now goes to the Senate, where passage is expected some time early next year.

The vote in the 350-seat Congress of Deputies was 184-158 with one abstention.

Abortion reform was the last major pending issue in a bold reform agenda undertaken by Prime Minister Jose Luis Rodriguez Zapatero, a Socialist who took power in 2004. Under Zapatero, Spain has also legalised gay marriage and made it easier for Spaniards to divorce in a drive that has infuriated conservatives and the Roman Catholic Church, AP reports.

Under the current law, which dates back to 1985, Spanish women could in theory go to jail for getting an abortion outside certain strict limits — up to week 12 in case of rape and week 22 if the fetus is malformed. But abortion is in effect widely available because women can assert mental distress as sole grounds for having an abortion, regardless of how late the pregnancy is. Most of the more than 100,000 abortions carried out each year in Spain were early-term ones that fell under this category.

The bill wipes away the threat of imprisonment and declares abortion to be a woman’s right. ‘We are legislating women’s right to decide whether to be mothers,’ said Carmen Monton, the Socialists’ spokeswoman on gender issues.

Conservative Popular Party spokesman Santiago Cervera insisted there was no clamour in Spanish society for changing the existing law and the government instigated it just to raise a stir and distract people’s attention away from the country’s economic recession.

The new bill, besides allowing unrestricted abortion up to 14 weeks, would permit it up to 22 weeks if two doctors certify there is a serious threat to the health of the mother, or fetal malformation. Beyond 22 weeks, it would be allowed only doctors certify fetal malformation deemed incompatible with life or the fetus were diagnosed with an extremely serious or incurable disease.

The new bill would also also allow 16- and 17-year-olds to have abortions without parental consent, as is the case in other European countries such as Germany, Britain and France.

This clause proved to be among the bill’s most controversial ones. In the end, the ruling Socialist party agreed to amend it so that such minors must inform their parents or legal guardian if they plan to undergo an abortion — although still with no need for their permission — except if they can show that doing so would expose them to violence within their family, threats or coercion.

The Spanish Bishops’ Conference warned last month that legislators who voted in favor of the bill would be sinning and no longer eligible to receive Communion. This was particularly touchy for parliamentary speaker Jose Bono, a Socialist who is a practising Catholic. Bono responded saying ‘My conscience is clear’.

In October, a rally against the reform bill drew hundreds of thousands of people to Madrid.

Spanish lawmakers vote to ease abortion law. Associated Press, 17 December 2009

Northern Ireland: Judge orders reconsideration of abortion guidance

The Department of Health in Northern Ireland has failed in a legal bid to stop the complete withdrawal of government guidelines on abortion. 

Last month, the High Court ruled they did not properly cover counselling and conscientious objection issues. Lawyers for the department argued that the sections on these two issues should be the only ones to be reconsidered.

However, Lord Justice Girvan said on 14 December that the whole guidance as currently issued was misleading, BBC News Online reports.

Abortion is illegal in Northern Ireland, except in limited circumstances where the mother’s life or mental well-being are considered at risk.

The document, which for the first time provided guidance to health professionals in Northern Ireland on terminating pregnancy, was published in March after a series of legal battles.

The anti-abortion group, Society for the Protection of the Unborn Child (SPUC), had brought judicial review proceedings in an attempt to win a declaration that the decision to publish the advice was unlawful. In last month’s ruling, Lord Justice Girvan stopped short of quashing the document but said it should be withdrawn because some of its advice was misleading.

The judge said that, as the guidelines stand, people could offer counselling which could arguably be seen to be breaking the law.

In Monday’s hearing, a barrister for the Department of Health described as ‘draconian’ his order for the advice to be completely withdrawn. Nicolas Hanna QC expressed concerns that it may lead some to believe the entire document was up for reconsideration.

He added: ‘It’s important to recognise that a challenge has been brought to this guidance, most of which has failed. In particular, the fundamental challenge to the guidance on the law in Northern Ireland has failed.’

David Scoffield, the lawyer representing Spuc, argued there was ‘a good deal of cross-fertilisation’ between the sections criticised and other parts of the guidelines.

Backing his argument, Lord Justice Girvan said:

‘There were aspects of the counselling section and the conscientious objection section that the court considered did not represent the correct legal position. They were significant portions of the guidance and the effect of the errors that the court sought to identify in the judgement made the guidance as issued as a whole misleading and requiring reconsideration. I’m not persuaded that one should view the document as complete self-contained, separate issues.’

He added: ‘This guidance requires to be withdrawn for reconsideration because two important sections of it require reconsideration. I don’t propose to vary my order in that regard.’

Abortion guidance must be redrawn. BBC News Online, 14 December 2009

Also read:

Guidance on the Termination of Pregnancy: The Law and Clinical Practice in Northern Ireland. Deparment of Health, Social Services and Public Safety. March 2009.

BPAS comment on the Judicial Review of the guidance on abortion care produced by the DHSSPS in Northern Ireland. BPAS, 30 November 2009

Northern Ireland: SPUC challenges abortion guidelines. Abortion Review, 28 October 2009

UK: Scheme allows pharmacies to provide contraceptive pills over the counter

An NHS pilot scheme is providing the contraceptive pill to teenage girls without prescription in pharmacies.

Southwark and Lambeth, two inner-city areas in London with the highest teenage pregnancy rates, are the first to try the approach, BBC News Online reports.

Experts have warned that the government is struggling to meet its target of halving teenage pregnancies by 2010. But opponents said there was no evidence providing the pill over the counter would make a difference.

Each local area has been given a target of a reduction of between 40% and 60%, for which responsibility is shared between the health service and local authority. In England in 2007, 42 of every 1,000 girls under the age of 18 became pregnant - the majority unintentionally. Half of those pregnancies ended with an abortion.

The idea of training pharmacists to provide the contraceptive pill was first proposed two years ago by then Health Minister Lord Darzi. He said there was strong evidence that better provision of contraception would significantly reduce unintended pregnancies.

Southwark PCT has been working for the past year to set up the project, developing a training course with King’s College London that could be adopted if the pilots were replicated elsewhere in the UK.

Initially, three pharmacies have been given permission to offer contraceptive consultations to girls aged over 16. For the past six weeks, young women asking for emergency contraception - the morning after pill - have been offered a private consultation on longer term alternatives. So far around 50 have chosen to switch over to an oral contraceptive after being taken through similar checks to those which would be carried out by a GP.

The pilot project is likely to attract criticism from those concerned that making contraception more readily available to 16-year-old girls might encourage them to have sex. Mark Haughton, from the Christian Medical Fellowship, is not convinced providing the pill without prescription will make any difference to teenage pregnancies. He said:

‘Doctors and pharmacists are at the end of the chain. What we need to do is to work on the whole area of relationships - that is what is effective.’

But Jo Holmes, from Southwark PCT, said it was taking a responsible approach to the reality that many teenage girls over the age of 16 were sexually active. Focus groups run by the NHS with young women suggested that some found it difficult to approach their family doctor.

The project has the approval of the Department of Health, which has previously used this approach of trying out potentially controversial policies in small-scale pilots. Emergency contraception (the ‘morning after pill’ ) became available in pharmacies nationally not long after pilot projects in Manchester provided enough data to allay concerns over safety.

Teenage girls to get contraceptive pill in pilot scheme. BBC News Online, 11 December 2009

Also read:

UK: Boots the chemist to sell Viagra over the counter; BPAS responds: Good news, but what about the contraceptive Pill? Abortion Review, 19 June 2009

Italy: ‘Abortion pill’ approved for use

The sale of RU486 has been given final approval in Italy, despite protests from the Vatican and the government in the Catholic country, BBC News Online reports.

Unlike in other European countries, the ‘abortion pill’, also known as mifepristone, will be administered solely in hospitals.

The drug was originally approved by the country’s pharmaceuticals agency in late July, but the move prompted a parliamentary inquiry.

Italy was is one of the last European states to make it available.

According to the country’s pharmaceutical agency, the pill must only be administered in a hospital environment and must be taken within seven weeks of conception. Women will be required to remain in hospital until the drug has taken full effect.

‘The debate is not yet over,’ Senator Donatella Poretti told Agence France Presse. ‘From tomorrow, we have to ask why Italian women [prescribed the drug] will be required to stay in hospital.’

The introduction of the drug had sparked outrage from the Vatican. Bishop Elio Sgreccia, vice-president of the Pontifical Academy for Life, had threatened women who used it, doctors who prescribed it and those who encouraged its use with excommunication.

Italian law permits surgical abortion on demand in the first 12 weeks of pregnancy, and then until the 24th week only if the fetus has a genetic deficiency or to preserve the mother’s health.

Abortion pill gets final approval in Italy. BBC News Online, 10 December 2009

Also read:

Italy: Government blocks ‘abortion pill’. Abortion Review, 30 November 2009

Ireland: Illegal abortion sends the problem abroad

Commentary by Ann Furedi, chief executive of BPAS.

Ireland is a modern developed country where women expect to live modern lives. They expect to be educated and to have the chance to work. They expect to be able to plan their families. They expect to enjoy sex without fear of pregnancy. And, as contraception can’t always be relied on, this means they need access to safe legal abortion, just as we do here in Britain.

Every year, BPAS clinics see hundreds of women who have travelled from Irish cities, towns and villages to end crisis pregnancies. Nothing obvious marks them from out from our English clients, except sometimes their accents. They come from the same social backgrounds and share the same mix of opinions and views, hopes, ambiguities and fears. But, whether they acknowledge it or not (some do, some don’t) they carry an additional burden of knowing that, in their own homeland, abortion is illegal; it violates the constitution.

The illegality of abortion at home has consequences even for those women wealthy enough, organised enough and informed enough to travel. It means they have limited opportunity for advice and counselling before they come here, and little access to support and aftercare when they return home. They carry the emotional burden of seeking an ‘illicit’ solution, and the financial cost of the treatment, travel and accommodation.

The practical arrangements often means their treatment is delayed. Many suffer needless anxiety because, in a country when abortion is unlawful, to can be hard to know facts from myths, and to information is trustworthy. The lies about abortion are so rife that BPAS counsellors in Liverpool, who see hundreds of Irish women each year, lobbied for a dedicated website to tell the truth.

Part of truth is that legal abortion is safe and benefits society. Another part of the truth is that Ireland can only exist as a modern society because abortion clinics exist in England to help its citizens manage their reproductive lives. We are the safe, civilised alternative to clandestine, illegal abortion treatments, to abandoned infants and the burdens of forced, unwilling motherhood.

Women in Ireland have abortions but they have them here, while politicians turn away from taking responsibility for a society that allows women to have hopes and expectations of equality, but denies them the means to achieve it and makes them prisoners of their biology.

Something seems unfitting when the European Court challenges the right of a nation to set its own laws. Democracy and the right of nations to self-determination are principles that we abandon at our peril. But when a country fails to address issues that undermine the health and wellbeing of its own citizens, it needs to hear the voices of those beyond its boundaries.

Abortion is a fact of life for women in Ireland. And the Irish Government needs to face that fact.

Ann Furedi is chief executive of BPAS. A version of this article was published in the Independent:

Ann Furedi: Seeking an ‘illicit’ solution carries an emotional cost. Independent, 10 December 2009

Also read:

Irish women take abortion law to court. Abortion Review, 7 December 2009

USA: Abortion surveillance, 2006

From MMWR Surveillance Summaries.

Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, New York City, and the District of Columbia); these data are provided to CDC voluntarily.

In 2006, data were received from 49 reporting areas. For the purpose of trend analysis, data were evaluated from the 46 areas that reported data every year during 1996-2006.

For 2006, a total of 846,181 abortions were reported to CDC. Among the 46 areas that provided data consistently during 1996-2006, a total of 835,134 abortions (98.7% of the total) were reported; the abortion rate was 16.1 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 236 abortions per 1,000 live births.

During the previous decade (1997-2006), reported abortion numbers, rates, and ratios decreased 5.7%, 8.8%, and 14.8%, respectively; most of these declines occurred before 2001. During the previous year (2005-2006), the total number of abortions increased 3.1%, and the abortion rate increased 3.2%; the abortion ratio was stable. In 2006, as during the previous decade (1997-2006), women aged 20-29 years accounted for the majority (56.8%) of abortions and had the highest abortion rates (29.9 abortions per 1,000 women aged 20-24 years and 22.2 abortions per 1,000 women aged 25-29 years); by contrast, abortion ratios were highest at the extremes of reproductive age.

Adolescents aged 15-19 years accounted for 16.5% of all abortions in 2006 and had an abortion rate of 14.8 abortions per 1,000 adolescents aged 15-19 years; women aged >or=35 years accounted for a smaller percentage (12.1%) of abortions and had lower abortion rates (7.8 abortions per 1,000 women aged 35-39 years and 2.6 abortions per 1,000 women aged >or=40 years).

During 1997-2006, the percentage of abortions and the abortion rate increased among women aged >or=35 years but declined among adolescents aged or=21 weeks’ gestation (1.3%).

During 1997-2006, the percentage of abortions performed at

Deaths of women associated with complications from abortions for 2006 are being investigated under CDC's Pregnancy Mortality Surveillance System. In 2005, the most recent year for which data were available, seven women were reported to have died as a result of complications from known legal induced abortions. No reported deaths were associated with known illegal induced abortions.

The authors interpreted these results as follows: Among the 46 areas that reported data consistently during 1996-2006, decreases in the total reported number, rate, and ratio of abortions were attributable primarily to reductions before 2001. During 2005-2006, the total number and rate of abortions increased. In 2005, as in the previous years, reported deaths related to abortions occurred only rarely. The authors concluded that abortion surveillance in the United States continues to provide the data needed to examine trends in the number and characteristics of women obtaining abortions. Policymakers and program planners can use these data to guide and evaluate efforts to prevent unintended pregnancies.

National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA 30333, USA.

Abortion surveillance - United States, 2006. Pazol K, Gamble SB, Parker WY, Cook DA, Zane SB, Hamdan S; Centers for Disease Control and Prevention (CDC). MMWR Surveillance Summaries. 2009 Nov 27;58(8):1-35.

Irish women take abortion law to court

Three women are to challenge the Irish government’s ban on abortion in a case at the European Court of Human Rights. 

One of the women sought an abortion because her doctor warned she was at risk of an ectopic pregnancy. The second accidentally became pregnant while she was undergoing chemotherapy for cancer. The third became unintentionally pregnant when she was trying to improve her personal circumstances in the hope of regaining custody of her children.

Lawyers will argue that the Irish ban jeopardises women’s health and wellbeing.

On 9 December, the women’s case will be heard in Strasbourg in front of 17 judges, with the Irish Government opposing. Abortion is criminalised under the Offences Against the Person Act of 1861, which threatens women who ‘unlawfully procure a miscarriage’ with life imprisonment.

The case of the three women, known as A, B & C, is being heard on the grounds that Ireland’s ban on abortion has jeopardised their health and wellbeing and violated their rights under the European Convention on Human Rights.

The women lodged a complaint to the European Court of Human Rights in August 2005, contending that the Republic of Ireland breached their human rights under Articles 2 (Right to Life), 3 (Prohibition of Torture), 8 (Right to Respect for Family and Private Life) and 14 (Prohibition of Discrimination) of the European Convention on Human Rights. If successful, the case would establish a minimum degree of protection to which a woman seeking an abortion to protect her health and well-being would be entitled, under the European Convention of Human Rights.

An expert submission was accepted by the court on the needs of Irish women travelling for abortion care and the problems caused by treatment delays imposed by this legal restriction. This was written by BPAS together with Doctors for Choice in Ireland, and Dr Ruth Fletcher, a medical lawyer at Keele University. Dr Fletcher has conducted ESRC-funded social research on the support services needed for women travelling from Ireland to access abortion care.

Ann Furedi, Chief Executive of BPAS, the charity that provides abortions and contraception in Great Britain to women travelling from the Republic of Ireland, said

‘Hundreds of women travel each year to BPAS from the Republic of Ireland in order to access safe, legal abortion care. This is provided to women in almost every other country as a matter of necessary and responsible law-making.’

Dr Patricia Lohr, Medical Director of BPAS, one of the charity’s many doctors and nurses caring for women travelling from the Republic of Ireland, said

‘Women from the Republic of Ireland often arrive for treatment alone, because they can’t afford to bring their partner or mother to accompany them. They are understandably very often apprehensive, having had to travel for hours or days to reach an unfamiliar clinic in England. It’s disturbing that the law in Ireland forces women to pay privately for care abroad. This creates weeks of delay before seeing a doctor while women try to borrow or save up money to pay for travel, accommodation and for their abortion.

‘The ban means that doctors in Ireland are not routinely issued with proper training and guidance to care for patients in the extremely common situation of seeking an abortion. Post-abortion aftercare and follow-up is not easily available in Ireland, meaning women may not get help if they need it, or have to pretend they’ve had a miscarriage to get help.

‘There is never any moral justification for the law to place a barrier between women and medical care. As doctors, we’re concerned at the needless burden of additional risk caused by treatment delays. You don’t have to be medically qualified to understand that the Irish abortion ban risks women’s physical health, requires abortions to be performed later than necessary, and creates serious emotional upset for women at an already stressful time.‘

Women challenge Irish abortion ban in court. Guardian, 7 December 2009

Press comment on the challenge to Ireland’s abortion ban to be heard in the European Court of Human Rights, 9 December 2009. BPAS, 7 December 2009

Moral authority in English and American abortion law

An interesting chapter by Joanna Erdman, of the Faculty of Law at the University of Toronto.

Abstract:

In R. (on the application of Axon) v. Secretary of State for Health & Another, the English High Court affirmed that young women are entitled to seek and receive sexual health care, including abortion care, without parental notification. This chapter examines the Court’s use of comparative constitutional authorities in its reasoning, focusing on the rejection of American authorities. Contrast and rejection, it is argued, can be an exercise in self-reflection, revealing how a court understands its own constitutional approach. Aversive constitutionalism presents opportunities to deconstruct claimed similarities and differences in constitutional approaches, to uncover and contest characteristics and assumptions otherwise unexamined.

This chapter uses the contrast and rejection of American authorities in Axon to expose a fundamental characteristic underlying the English constitutional approach to young women’s abortion care. It is a shared rather than contrasted characteristic in American and English law. The characteristic is moral authority, defined as the legal authority to protect a state interest in prenatal life through moral abortion decision-making. Both American and English abortion law seek to protect a state interest in prenatal life by entrusting decision-making about young women’s abortion care to third parties: the family, the court, and the medical profession. Neither constitutional approach vests moral authority in young women themselves.

Part I deconstructs the aversive constitutional move in Axon to expose the shared characteristic of third-party moral authority and the supporting set of assumptions underlying it. Part II turns to the assumptions themselves. The first assumption is that the involvement of third parties necessarily improves the moral quality of abortion decision-making. The second assumption is that such improvement is required. It is argued that both assumptions are gendered. Young women are denied moral authority on a feminine-gendered assumption of their underdeveloped capacity to engage in moral decision-making. The family, the court, and the medical profession are granted moral authority by virtue of their masculine-gendered identity. Third-party moral authority for this reason requires constitutional reform. Part III seeks to develop a reformed vision of moral authority in abortion law from the perspective of gender equality. It offers a constitutional approach that protects the state interest in prenatal life by entrusting and supporting the decision-making of young women, privileging the unique moral insight of their individual experience.

This chapter is published in Constituting Equality: Gender equality and comparative constitutional law, Susan H. Williams, ed., pp. 107-132, Cambridge: Cambridge University Press, 2009

Contact information: Joanna Erdman, University of Toronto - Faculty of Law, 78 and 84 Queen’s Park, Toronto, Ontario M5S 2C5, Canada. Email:

Northern Ireland: abortion care guidance withdrawn

BPAS comments on the Judicial Review of the guidance on abortion care produced by the DHSSPS in Northern Ireland.

Lord Justice Girvan at the High Court in Belfast made a ruling today granting the withdrawal of the Guidance document on abortion from Northern Ireland’s Department of Health, Social Services and Public Safety (DHSSPS) following a Judicial Review instigated by SPUC (an anti-abortion group). The court found in the DHSSPS’s favour in six out of eight aspects contested by SPUC.

The new document had aimed to clarify the situation for healthcare professionals in Northern Ireland around the law relating to termination of pregnancy. Ann Furedi, Chief Executive of BPAS, the charity which provides abortion and contraceptive care in Great Britain to women travelling from Northern Ireland, said in response to the decision

‘Forcing a woman to endure a pregnancy and have a child that she doesn’t want and can’t look after is undoubtedly extremely damaging to her and to her existing family.

‘We see hundreds of women each year from Northern Ireland who have been forced to travel to access healthcare services which are legitimately provided to women in almost every other country.’

BPAS comment on the Judicial Review of the guidance on abortion care produced by the DHSSPS in Northern Ireland. BPAS, 30 November 2009

Also read:

Northern Ireland: SPUC challenges abortion guidelines. Abortion Review, 28 October 2009

Finland: Immediate complications after medical compared with surgical abortion

From Obstetrics and Gynecology.

The study set out to estimate the immediate adverse events and safety of medical compared with surgical abortion using high-quality registry data.

All women in Finland undergoing induced abortion from 2000-2006 with a gestational duration of 63 days or less (n=42,619) were followed up until 42 days postabortion using national health registries. The incidence and risk factors of adverse events after medical (n=22,368) and surgical (n=20,251) abortion were compared. Univariable and multivariable association models were used to analyse the risk of the three main complications (haemorrhage, infection, and incomplete abortion) and surgical (re)evacuation.

The authors found that the overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Haemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death.

The authors concluded that both methods of abortion are generally safe, but medical termination is associated with a higher incidence of adverse events. These observations are relevant when counseling women seeking early abortion.

Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland.

Immediate complications after medical compared with surgical termination of pregnancy. Niinimäki M, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O. Obstetrics and Gynecology. 2009 Oct;114(4):795-804.

Italy: Government blocks ‘abortion pill’

The centre-right government of Silvio Berlusconi has blocked availability in Italy of early medical abortion, which is vehemently opposed by the Vatican and the Catholic Church. 

RU486, or mifepristone, has been approved by AIFA, the Italian pharmaceutical authority, for use in hospitals under medical supervision as an alternative to surgical abortion up to the 49th day of pregnancy. It was first introduced in France in 1988 and is now used widely in Europe, though not in predominantly Catholic countries such as Portugal, Ireland and Poland.

But on 26 November the Senate health commission suspended its use and asked the Health Ministry for ‘a second opinion’ on the grounds that the pill could endanger women’s health or violate Italy’s anti-abortion laws, The Times (London) reports.

The pill, which suppresses a hormone called progesterone, causing the uterine lining to reject an implanted embryo, allows a woman to have a chemically induced abortion instead of surgical procedure. It is regarded by the Church as ‘back door abortion’ and was condemned by the Vatican in a document last year on bio-ethics, together with artificial fertilisation, human cloning, ‘designer babies’ and embryonic stem-cell research.

Abortion in the first 90 days of pregnancy was legalised in Italy in 1978. However Maurizio Sacconi, the Welfare and Health Minister, said that ‘Italy’s abortion laws were not conceived with a pharmaceutical solution in mind’.

Anna Finocchiaro, leader in the Senate of the opposition centre Left Democratic Party, said the Berlusconi government’s real aim was to ban the pill altogether. ‘Instead of admitting what they really want, they’re hiding behind a lot of chatter’, she said.

Felice Belisario, head of the centre-left Italy of Values party in the Senate, said that the move was an ‘absolutely indecent blow to women’s rights’. It was ‘a step backward compared to more evolved countries. For the centre right, science stopped a hundred years ago’.

Commenting on this development, Patricia Lohr, Medical Director of BPAS, said

‘Early medical abortion is an extremely safe procedure. Medical abortion, and the drug Mifepristone, increases access to abortion early in pregnancy, when we know it is safest and has been approved for use by regulators in most countries where abortion is legal, including the USA, Canada and Britain. 

‘More women every year opt for early medical abortion as a choice of method because it is non-invasive and non-surgical and they should feel confident that they are being offered a safe, effective treatment.’

The Italian consumer group Aduc said that the pill had been in use for over twenty years in France and eight years in the United States ‘without any problem’. Mr Berlusconi has come under fire from the Catholic Church over his ‘immoral’ private life, but has assured the Vatican that his Government wll pass laws that take into account Catholic views on bio-ethical issues from abortion to euthanasia.

According to the Italian Health Ministry, 70 per cent of Italian doctors are ‘conscientious objectors’ who exercise their right under the law to refuse to carry out abortions.

Berlusconi Government blocks Vatican-opposed RU486 abortion pill. The Times (London), 26 November 2009

BPAS responds to the Italian Government blocking access to early medical abortion in hospitals. BPAS, 27 November 2009

Also read:

Italy: ‘Abortion pill’ approved for use. Abortion Review, 31 July 2009

MSI leads discussion on using family planning to combat climate change

Press release from Marie Stopes International, 27 November 2009. 

London - Marie Stopes International is leading the global discussion on the ways in which family planning could be used to combat climate change.

MSI has been at the forefront of the debate and was mentioned heavily in the global media recently thanks to a ground-breaking paper on the links between climate change and women’s reproductive health needs in developing countries. The lead researcher and author of the article, published in November’s Bulletin of the World Health Organisation (WHO), was MSI’s Leo Bryant.

Climate change continues to be a hot topic, particularly With the UN Climate Change Conference in Copenhagen coming up in early December. However the link between family planning and environmental impact has been largely overlooked. Some have suggested family planning could help to reduce carbon emissions while others are concerned that this is tantamount to ’blaming climate change on the fertility of the poor’. But MSI is not an organisation to shy away from difficult and neglected subjects.

The angle MSI has taken does not focus on reducing carbon emissions but on empowering women to cope with climate change. This ‘adaptation’ approach reflects concerns articulated by governments in developing countries who will be worst affected.

The research published in the Bulletin is based upon a literature review of climate change adaptation strategies – or ‘National Adaptation Programmes of Action’ (NAPAs) – written by developing country governments. The findings highlight that 37 of the 40 strategies sampled identified ‘rapid population growth’ as a factor that either causes or exacerbates environmental damage. The article concludes that efforts to improve voluntary access to family planning should therefore be integrated into climate change adaptation strategies in order to better support communities struggling to cope.

The release of the research generated at least 50 articles worldwide and was covered by major news sources including Reuters, Bloomberg, Fox News and The New York Times. It also generated a number of articles on websites ranging from pheethiopia.org to catholicnewsagency.com as well as postings on various blog sites. The UK’s leading medical journal The Lancet also ran an editorial picked up by further newswire services including The Associated Press and The Daily Telegraph.

With the UN Copenhagen conference on climate change already grabbing headlines this discussion will continue to be a hot issue and MSI is at the forefront.

You can view the full article here.

Family planning to tackle climate change. MSI, 27 November 2009

UK: Women’s preferences for method of abortion and management of miscarriage

From Journal of Family Planning and Reproductive Health Care. 

The authors note that there is growing interest in the UK towards increasing treatment options for women undergoing abortion and miscarriage. Such options include home medical treatment and surgery under local anaesthesia (LA).

This study aimed to gauge views of women undergoing abortion and treatment for miscarriage at the Royal Infirmary Edinburgh towards medical treatment at home, and surgery under LA, to determine whether new services should be developed. The study consisted of a self-administered anonymous questionnaire.

A total of 148 questionnaires were completed by women undergoing a medical abortion (n = 97; 66%), surgical abortion (n = 30; 20%) or surgical management of miscarriage (n = 21; 14%). Women having an abortion expressed a future preference for medical abortion in hospital (n = 64; 52%) at home (n = 31; 25%) or by surgery under general anaesthesia (GA) (n = 20; 17%) or LA (n = 7; 6%). Women having a miscarriage expressed a future preference for surgery under GA (n = 7; 35%), LA (n = 6; 30%) or medical management at home (n = 4; 20%) or in hospital (n = 3; 15%).

The authors concluded that this study shows that medical abortion at home is a potentially popular choice for women having an abortion, with surgical abortion under LA less so. Both home medical management and surgery under LA would appear to be welcome service developments for women needing treatment for a miscarriage.

University of Edinburgh, Edinburgh, UK.

Women’s preferences for method of abortion and management of miscarriage. Levine K, Cameron ST. Journal of Family Planning and Reproductive Health Care. 2009 Oct;35(4):233-5.

MSI launches tool to calculate the effect of its programmes in 42 countries

Press release from Marie Stopes International, 16 November 2009. 

Kampala: Global family planning and reproductive health agency Marie Stopes International (MSI) today launches a new measurement tool which will enable government health departments, hospitals, NGOs and other agencies to accurately calculate the effect of family planning programmes on the wider health, economic, environmental and societal outcomes of the communities and countries in which they work.

The Impact Calculator integrates several validated and commonly used models and formulae into a single, user friendly application which allows any organisation to calculate the impact of its own family planning services on a community, national, regional or global level.

Using the tool, it is possible to calculate demographic and health impacts such as the number of pregnancies and abortions averted, and the number of maternal, infant and under-5 deaths prevented; economic impacts such as the total savings made to household, community and health systems’ budgets; and environmental impacts, such as the ecological footprints averted (the sum of land and sea required to provide food and resources consumed by each person, to provide space for infrastructure and to absorb waste).

The Impact Calculator will be previewed by MSI’s Director of Strategy and External Affairs, Michael Holscher, at a reception held at the International Conference on Family Planning in Kampala, Uganda today.

Using the Impact Calculator to calculate the effect of MSI’s own programmes in 42 countries worldwide, Holscher reveals that, to date in 2009 MSI’s family planning services have:

- prevented almost seven million unplanned pregnancies
- averted more than two million abortions
- saved household, community and health system budgets over US$1 billion
- prevented over four million ecological footprints

“When the Impact Calculator becomes available to third party agencies in 2010,” said Holscher, “it will enable anyone working in the field of sexual and reproductive health to demonstrate persuasively to governments and donors how an investment in family planning programmes can have a transformative effect at every level of society – from saving lives and improving the living conditions of families and whole communities to improving national health outcomes and contributing to economic and ecological sustainability.”

The Impact Calculator will become available to third party agencies in the New Year.

New measurement tool will provide clear evidence of the impact of family planning programmes on communities’ health and economic wellbeing. MSI, 16 November 2009

Northern Ireland: Figures show number of abortions

Official statistics released in response to an assembly question asked by SDLP MLA Pat Ramsey revealed that 92 women had pregnancy terminations in 2008. 

Seventy nine women underwent the procedure in NI the previous year, BBC News Online reports.

Abortion is illegal in Northern Ireland, except when the mother’s life is at risk.

In May, a Department of Health report revealed that 1,173 women had travelled to England to have an abortion last year, in comparison to 1,343 for 2007.

Anti-abortion campaigners are currently mounting a legal action in an attempt to quash government guidelines on abortion in Northern Ireland which were published in March this year. The campaigners claim the guidance issued to health professionals is misleading and legally inaccurate.

Slight rise in NI abortion rate. BBC News Online, 10 November 2009

USA: Abortion in adolescents - epidemiology, confidentiality, and methods

From Current Opinion in Obstetrics and Gynecology.

The purpose of this study was to review the epidemiology, confidentiality, and methods of abortion provision specific to adolescents.

It found that in the United States, four out of five pregnancies in teenagers are unintended and about one-third of all adolescent pregnancies end in induced abortion. Barriers such as travel and cost decrease abortion access for all women and adolescents, whose pregnancies are diagnosed later than older women, may be particularly impacted by such challenges.

An increasing majority of states require parental involvement in adolescents’ decisions to end their pregnancies. Recent analyses indicate that mandating parental involvement does not promote family communication; rather, such laws may actually increase the risk of harm by delaying appropriate medical care. Medication and surgical abortion are options for adolescents; both are safe and effective. There is no evidence that abortion during adolescence causes negative psychological consequences, decreased fertility, or increased risk in future pregnancies.

The authors summarised that continued high rates of unintended pregnancy among US adolescents necessitate access to safe and timely abortion services. Unfortunately, teens encounter unique barriers in obtaining abortion care that lead to delays and preventable risk associated with later abortion.

Columbia University, New York, New York, USA. Email:

Abortion in adolescents: epidemiology, confidentiality, and methods. Davis AR, Beasley AD. Current Opinion in Obstetrics and Gynecology. 2009 Oct;21(5):390-5.

USA: Health bill passed by House of Representatives

US President Barack Obama said he was ‘absolutely confident’ the Senate would pass its own version, and that healthcare reforms would become law by the end of the year. 

Passed in a narrow 220-215 vote by the House, the bill aims to extend coverage to 36 million more Americans and provide affordable healthcare to 96%.

Mr Obama has made healthcare reform a central plank of his domestic agenda, BBC News Online reports. Correspondents say the legislation could lead to the biggest changes in American healthcare in decades.

Democratic Senators must now consider their own bill. They need 60 out of 100 votes to bring it to a final vote. There are only 58 Democrats and two independents in the Senate. Two Republicans have signalled they could approve a compromise health bill. If it is passed, lawmakers from both houses will try to reconcile the two versions before the programme can be signed into law by the president.

In the vote on 7 November, the bill was supported by 219 Democrats and one Republican - Joseph Cao from New Orleans. Opposed were 176 Republicans and 39 Democrats.

Mr Obama said:

‘Tonight, in an historic vote, the House of Representatives passed a bill that would finally make real the promise of quality, affordable healthcare for the American people. The United States Senate must follow suit and pass its version of the legislation. I am absolutely confident it will, and I look forward to signing comprehensive health insurance reform into law by the end of the year.’

The bill will allow the government to sell insurance in competition with private companies and make insurers offer cover to those with pre-existing conditions. However, the government-run healthcare programme - the so-called ‘public option’ - was scaled back in the run-up to the vote.

The debate had sparked strong emotions on both sides, BBC News Online reports. Before the vote, Mr Obama had made a rare visit to Congress to try to persuade wavering members of his own Democratic Party to back the bill.

One key concession to get the bill through was to anti-abortion legislators. An amendment was passed that prohibits coverage for abortion in the government-run programme except for rape, incest or if the mother’s life is threatened. Private plans can still offer the cover.

Democrat Bart Stupak, who sponsored the amendment, said: ‘Let us stand together on principle - no public funding for abortions.’

Abortion rights supporters said the amendment was the biggest setback to their cause in decades.

Obama says health vote ‘historic’. BBC News Online, 8 November 2009

Q&A: US healthcare reform. BBC News Online, 20 November 2009

New Zealand: Reactions to abortion and subsequent mental health

From The British Journal of Psychiatry.

The authors note that there has been continued interest in the extent to which women have positive and negative reactions to abortion. This study aims to document emotional reactions to abortion, and to examine the links between reactions to abortion and subsequent mental health outcomes.

Data were gathered on the pregnancy and mental health history of a birth cohort of over 500 women studied to the age of 30.

The results found that abortion was associated with high rates of both positive and negative emotional reactions; however, nearly 90% of respondents believed that the abortion was the right decision. Analyses showed that the number of negative responses to the abortion was associated with increased levels of subsequent mental health disorders (P<0.05).

Further analyses suggested that, after adjustment for confounding, those having an abortion and reporting negative reactions had rates of mental health disorders that were approximately 1.4–1.8 times higher than those not having an abortion.

The authors concluded that abortion was associated with both positive and negative emotional reactions. The extent of negative emotional reactions appeared to modify the links between abortion and subsequent mental health problems.

Christchurch Health and Development Study, Department of Psychological Medicine, University of Otago, Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

Correspondence: David M. Fergusson, Christchurch Health and Development Study, University of Otago, Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand. Email:

Reactions to abortion and subsequent mental health. David M. Fergusson, PhD, L. John Horwood, MSc and Joseph M. Boden, PhD. The British Journal of Psychiatry (2009) 195: 420-426. doi: 10.1192/bjp.bp.109.066068. © 2009 The Royal College of Psychiatrists

Abortion and fertility treatment: Whose right to choose?

Commentary by Ann Furedi, chief executive of BPAS.

The philosopher John Stuart Mill said that it is better for an individual to encompass his own destruction than ‘the evil of allowing others to constrain him for what they decide to be his good.’ This essentially sums up my view about the decisions that people face regarding their reproductive future.

In debates about abortion I am often challenged by people who ask: ‘Don’t women sometimes make the ‘wrong’ decisions?’ ‘How do we stop people from making a ‘bad’ choice?’ ‘How do we know they’re not going to regret their abortion?’ ‘Do you, personally, always agree with what women decide?’ ‘What about the woman who comes to you wanting an abortion because, say it interferes with her holiday, but who says she wants to get pregnant again the following year?’ ‘Can you say that she’s making the right decision?’

I always feel that it’s not for me to say whether the decision any woman makes is right for her. Some women make decisions around abortion that I, personally, think are wrong. I’ve had some interesting discussions with our counsellors, where I’ve been told: ‘You can’t ever say that women make the wrong decision because the decision making process is so complicated. Maybe she is saying that she wants the abortion so she can go on a skiing holiday, but, behind this, there will be a lot of other reasons’. That may be true, and I believe it usually is. But, what if a woman is making her decision ‘just’ because she wants to ski that black run? Or because she wants her dress to fit for the dance?

I believe that, for whatever reason a woman makes a decision about the future of her pregnancy, it is for her to make because, ultimately, she is the person who will live with it. When that woman looks at herself in the mirror every morning, she knows she lives in the life shaped by what she decided: either she has a child as a result of that choice, or she doesn’t.

It is because I have a firm belief that people should, and must, take responsibility for their decisions that I think that we need to be respectful of these choices, even when we do not agree with them. I believe it is wrong for us to deny people the capacity to make these intimate, personal choices. Tolerance of this freedom for others to decide what we would not is the price that we pay for living in a liberal society.

In relation to fertility treatment, as with abortion, I can appreciate the frustration that clinicians feel when women seem to be making irrational and unwise choices. I understand why, sometimes, they feel that couples should be prevented from making choices that may not lead to the best outcome - for example, when a couple insists on using two or three embryos when a single-embryo transfer would be far preferable from a clinical point of view. But, at the end of the day, personally, I am very hostile to legislation and regulation that prevents (although some would say ‘protects’ ) people from being able to make the wrong choices. For me, the freedom to make personal decisions in these matters is an issue of principle which is related to the question: ‘Whom do we trust?’, and our view on whether people can be responsible for making complex decisions for themselves.

I assume that people are generally capable of making rational, sensible decisions. When it comes to single-embryo transfer, for example, the onus should be on clinicians to communicate effectively and so convince patients of the advantage of this. And not seek to hide between rules and regulations that allow them to avoid this engagement, by simply maintaining a course of action is ‘not allowed’. Of course, this is what many doctors do – they have an ‘adult’, respectful dialogue.

If I were a 39-year-old woman undergoing fertility treatment, I would want to ask my doctor: ‘in my own specific circumstances, what is the best way of giving me my best chance of having a successful healthy pregnancy?’ If I believed that my doctors and I shared the desire for the best possible outcome, why would I not take their advice? That advice might be to use three embryos, or one embryo, or whatever, but I would want it to be a rational decision, determined by a clinician’s assessment of my personal needs. I certainly would not want any decision that requires clinical assessment to be determined by the views of the members of a regulatory authority made up of actors, bishops and journalists. Nor would I wish it to be made by parliamentarians – whether elected or not.

Clinical decisions should be taken according to what will give the patient the best outcome. Of course, these choices are made within a moral framework but women and their doctors have the capacity to make these decisions for themselves, and the capacity to manage the consequences.

I am not insensitive to the debates concerning the welfare of the potential child. Nor about the implications of individual choices for the rest of society. But a woman who is taking the decision to end a pregnancy is taking a decision not to have that child at all, to end the life before it has started, and there is no child whose welfare we need to consider. This is true regardless of the reason why the pregnancy is terminated.

Many of us may have very strong views about the morality of bringing a child into the world, or of deliberately ending that life before it’s begun. Or we may have very definite views about bringing a particular type of child into the world – for example a child that has a learning disability, or a severe physical and, perhaps, very painful impairment. Our views may differ, according to the qualities that we value, which is why I believe strongly that such choices regarding life and death, must remain with those most intimately affected by that decision. Putative parents, in consultation with their doctors, must make their own decisions as to whether or not they are prepared to face the relative risks of a multiple pregnancy – or the consequences of a congenital abnormality or those of terminating the pregnancy.

When it comes to these matters of family life and procreation, it really should be down to the parents, and ultimately the woman who will be carrying the pregnancy, to make that decision. Even if that decision is one that we disagree with or that goes against the grain of what society holds to be good sense. The abilities to exercise autonomy in decision making, and to base our choices on complex moral considerations, are central to what makes us human.

We need to be free to make the wrong choices if we are to be free to make the right ones. When governments, or their regulatory committees, take away our capacity to be wrong, they simultaneously take away our capacity to be right. And that is a degrading and intolerable assault.

This is an edited version of a speech given by Ann Furedi at the Battle of Ideas, 31 October 2009. Ann Furedi was speaking in a personal capacity.

Also read:

A Doctor’s Right to Choose: The dishonesty of English abortion law, by Professor Sally Sheldon. Abortion Review, 6 November 2009

Three’s a crowd? The battle over population and reproduction, by Dr Ellie Lee. Abortion Review, 6 November 2009

A Doctor’s Right to Choose: The dishonesty of English abortion law

Commentary by Sally Sheldon, professor of law at Kent Law School.

The English Parliament has shown a regrettable tendency to hand over controversial decisions regarding reproduction to clinicians rather than trusting women, or in certain circumstances couples, to make those decisions for themselves. While similar points might be made about the Human Fertilisation and Embryology legislation, the Abortion Act (1967) seems to me to be the most extreme and egregious example of this tendency, and it is this example I will outline here.

If you look back to the debates which preceded the introduction of the Abortion Act in the late 1960s, these were advanced a series of assumptions about the kind of woman who would seek to terminate a pregnancy. So we have desperate, multi-child mothers with alcoholic husbands who are incapable of raising a child, we have selfish, immature, promiscuous teenagers who are incapable of raising a child. What we don’t see are morally capable, rational women who are capable of making decisions for themselves. And in that context and relying on that set of values, it is probably not surprising that Parliament took the decision to hand over the abortion decision to high-minded, responsible clinicians rather than to women ourselves.

Abortion is clearly legal in Britain, but what is meant by that is that it is permissible. It’s not a right: no woman here has a right at any point in her pregnancy to terminate that pregnancy – what she can do is go and ask two doctors to make that decision for her. So the assumption that’s embodied in the 1967 Abortion Act is that this deeply personal reproductive decision is better made by a clinician than by the woman herself.

In practice, this has led to in practice a very liberal access to abortion in this country. Many clinicians, indeed most clinicians, aren’t very comfortable scrutinising women’s reasons for abortion and see it as a decision that belongs to the woman herself. So you might be tempted to say, ‘Well, why are you talking about this, does it matter?’ I think it does matter. It matters firstly because principles matter – it matters what the principles that underpin legislation are, it matters what the basis of our legislation is.

It also matters because gender is deeply relevant here. An unwillingness to let individuals make their own reproductive decisions means, in this instance, an unwillingness to let women make their own decisions. And that fits very neatly into a long and ignoble tradition in English law of giving decisions to someone else because women aren’t capable of making them for ourselves. It’s less than 150 years since all women have been able to own our own property, for example.

Finally it matters because the law poses a range of practical problems for those who provide abortion services. If you have a piece of legislation that says that this decision belongs to clinicians, this clearly offers scope for clinicians who aren’t sympathetic to termination to place hurdles in the path of women who are looking for abortions. The fact that that might not happen to many women, or it might not happen very often, does not mean that it shouldn’t concern us - because the women that it’s going to matter most for are the most vulnerable women, the women who don’t have English as their first language, who don’t know their way around the system, who live in rural areas where they haven’t got ready access to an alternative healthcare provider, and so on. So I think this is profoundly important.

I am not saying that I don’t think that doctors have any important role to play here. Clearly, they do. Clearly, clinicians must advise women on medical risks and benefits, and they must provide high quality of treatment. What they need to avoid, however, is the confusion of what is a moral and what is a medical decision, which allows them to make moral and personal decisions for women. I recognise that in areas of clinical practice this is difficult because these different factors can merge together, but I think what we need to do is get a lot better at trying to separate out moral decisions from medical or clinical ones.  Above all, we should be aware of the disingenuity and political expediency of Parliament when it tells us that something is a medical matter, when really we can see that it is an issue in which all these moral and social issues are highly implicated.

Finally, I would note that I don’t come to this view because I believe that abortion is a morally insignificant decision. I think the decision whether to continue a pregnancy, whether to bring a child into the world, is a deeply morally serious issue. The issue of the moral status of the fetus is profoundly important. My own position is that the fetus isn’t a full moral person worthy of equivalent moral respect to someone who has been born, but that isn’t to say that the embryo or fetus has no moral worth. Where I differ from some people in this debate, however, is that I believe that women are capable of making morally significant decisions and, indeed, that they are better equipped to make decisions that are going to affect every aspect of their future lives than a doctor whom they may never have met before and who may have very limited insight into their social situation.

What changes would I like to see to the abortion legislation in the 21st century? Firstly, I would like more honesty about what is a medical question and what is a moral or social question. What happens all too frequently in debates about reproductive choice is that moral assumptions and moral values are smuggled in. This happens when an abortion decision is described as primarily a clinical or a medical decision. It can also happen when moral judgements are smuggled in under the guise of resource allocation, when it is argued that certain kinds of women can’t be treated because we can’t afford to treat everyone. Of course resources are finite and not all treatments can be funded, but we need to be clear about when a refusal is based on clinical grounds and when it is based on moral grounds. 

So the first thing I would like is more transparency about the values that we’re bringing to these debates, and honest recognition when these are moral values rather than clinical or medical considerations. And my second hope for the 21st century is that we might begin to trust women to make reproductive decisions for ourselves. 

Professor Sally Sheldon is professor of law at Kent Law School, University of Kent. This is an edited version of a speech given by Professor Sheldon at the Battle of Ideas, 31 October 2009.

Also read:

Three’s a crowd? The battle over population and reproduction, by Dr Ellie Lee. Abortion Review, 6 November 2009

Abortion and fertility treatment: Whose right to choose? By Ann Furedi, Abortion Review, 8 November 2009

Three’s a crowd? The battle over population and reproduction

Commentary by Ellie Lee, co-ordinator of Pro-Choice Forum.

The debate about population has a long history. It is normally understood as a contest between two movements, each of which has a different view on the effects of population size for wider social and economic outcomes. Historically, the pro-natalist movement stands on one side of the debate, essentially viewing people as the driver of development and growth. On the other side, the anti-natalist movement sees people as a drain on natural and social resources.

Both these are complex movements with different, and often contradictory, aspects and taking support from different constituencies. The Catholic Church has played an important part in the pro-natalist movement, and continues to do so. At the current time, the most significant proponents of the anti-natalist cause are environmentalist lobby groups, including the Optimum Population Trust with its recent campaign to encourage couples to ‘Stop At Two’ children.

The way this discussion has developed in recent years provides the opportunity to repose the debate, and consider the population issue in different way. I would argue that the pro-natalist and anti-natalist movements have more in common than sets them apart. Both consider it appropriate for reproductive decisions to become the subject of campaigns and crusades that seek to influence attitudes behaviour in this area of life. So the Catholic Church encourages women to see any conception as gift from God. The environmental movement encourages women to see more than two children as potential ‘emitters’ of carbon dioxide.

These two movements share the view that private life is a legitimate focus for efforts to create what campaigners believe is a better society. This is the view that I am opposed to. I believe that the moralisation and politicisation of private life is problematic in whatever form that takes, and we need to protect decisional autonomy – the idea that individuals should, by and large, be allowed to do what they feel is right for them.

Childbearing decisions are of course influenced by many factors. Historically and across societies, levels of economic development are a major influence. In modernity, however, one important social and cultural premise is ‘decisional autonomy’, the notion that we can and should make our own decisions about certain aspects of life – including whether to have children, and how many to have. This notion rests in turn on the presumption that there is an important distinction between the private and public arenas of social life.

These suppositions about childbearing are important ones, and represent a great gain for civilised society. Yet private life is a fragile thing, and the process of founding and growing families demands a lot of people. It is profoundly unhelpful to make the conduct of private life subject to external moral imperatives, such as religious or political beliefs about the right number of children to have or the wrongness of avoiding unwanted children.

Another area worth highlighting is the dishonesty in way this debate is framed by the pro-natalist and anti-natalist movements. Both sides know that there is strong cultural resistance to restrictions on reproductive choice; that repressive population control measures are resented by the populations they affect: as with the One-Child Policy in China. It is no accident that the pro-life lobby and the Optimum Population Trust both couch their arguments in terms that appear woman-friendly. ‘Pro-lifers’ tell us that they oppose abortion because it is bad for women’s physical and emotional health. The Optimum Population Trust goes to great lengths to emphasis the voluntary nature of its campaign to get women to have small families.

Both sides of this debate fight shy of arguing that the law should restrict choice, either by preventing women from accessing abortion or compelling women to limit their fertility. Both are also keen to tell us that ‘evidence’ proves their case. Abortion opponents say that science shows that abortion is bad for women, leading to breast cancer or mental illness. Those who promote fertility reduction claim that ‘the evidence’ shows not only that we need to have small families to save the planet, but that women often have babies because they are unable to access and properly use good contraception.

There is a debate to be had about the ‘evidence’ itself in regard to these claims, and what research really does tell us about the health effects of abortion, or about the causes of unplanned pregnancies and how these pregnancies are resolved. For example, it is not the case that most third or fourth conceptions are involuntary, in the sense that they result from clearly unwanted pregnancies where abortion was denied. Some are undoubtedly unplanned, because contraception fails and people fail to use it. But what happens is that women and their partners then decide that to have another sibling is the best thing for them and the children they have already. The selective and distorted use of ‘evidence’ in relation to these matters reveals the dishonesty of the claim that campaigners are respecting women’s needs, as they argue over reproductive choices and behaviour.

What is being said in the discussion about population reduction is that the intimate and personal feelings and sensibilities of people should be influenced and shaped by the claim we should ‘stop at two’. For this reason, the real nature of project of the Optimum Population Trust, just like that of the Catholic Church, is a moral one. It seeks to breach the line between public and private life, and make our feelings and sentiments about pregnancies and how to resolve them a matter for intervention and manipulation by others.

Dr Ellie Lee is senior lecturer in social policy at the University of Kent, and co-ordinator of Pro-Choice Forum. This is an edited version of a speech given by Dr Lee at the Battle of Ideas, 31 October 2009.

Also read:

Battle of Ideas: a matter of choice, by Ellie Lee. Times Online, 30 October 2009

Commentary: Population, the environment, and a woman’s right to choose, by Jennie Bristow. Abortion Review, 3 October 2009

A Doctor’s Right to Choose: The dishonesty of English abortion law, by Professor Sally Sheldon. Abortion Review, 6 November 2009.

Abortion and fertility treatment: Whose right to choose? By Ann Furedi, Abortion Review, 8 November 2009

UK: No opt-out for sex education, government decides

Parents’ right to pull their children out of sex education classes in England is being ended once the pupils turn 15.

The change means all pupils will get at least one year of sex and relationship education before their 16th birthday once it becomes compulsory in 2011, BBC News Online reports.

Under these plans, even faith schools will have to cover areas such as same-sex relationships and contraception. However, governing bodies will still be able to ensure classes reflect the religious ethos of the school.

Under current rules, parents have the right to withdraw their child from sex and relationship education (SRE) classes up until the age of 19. Children’s Secretary Ed Balls said that currently only a ‘very small minority’ of parents chose to exercise this right. But over the past few months there had been debate about the age at which parents should still be able to remove their children from such classes, he said.

‘What’s happened over the past few decades is that the English courts have been saying it is important to strike a balance of the capacity of the young person to make their own decisions and the rights of the parents,’ he said.

Mr Balls suggested with the age of consent being 16 and with young people being able to vote at 18, it did not make sense for parents to have control over whether their children attended sex education classes right up until the age of 19: ‘I have concluded that parents right to withdraw their children from sex and relationship education should continue until their children reach the age of 15.’ This was based on what was ‘balanced, practically deliverable and legally enforceable’, he added.

The move does go back on what the government had said it would do when it received a report it commissioned on the subject back in March 2009. At this stage the opt-out was to be kept intact. However, polling for the Department for Children Schools and Families suggested that the vast majority of parents believed the opt out should end at an earlier age. Mr Balls said he hoped the age limit of 15 offered the best chance of building ‘a strong consensus’.

As a third of schools in England are faith schools, having the support of representatives of Anglican and Catholic church is vital if the policy is to be a success, BBC News Online reports.

Sir Alasdair Macdonald, the east-London head teacher who led the review on sex education, said:

‘I am pleased the government is taking forward my recommendations, including that schools should involve parents in developing their SRE policy. I support the government’s decision to limit the parental right of withdrawal, given the importance of SRE for all young people.’

The Catholic Education Service said it welcomed the government’s reiteration of its support for the important principles underlining SRE and that governing bodies retain the right to determine what is taught, and must determine this in line with the ethos of the school.

Sex and relationship education - who does what?

Age 5-7 - puberty, relationships and how to keep safe
Age 7-11 - puberty, relationships including marriage, divorce, separation, same sex and civil partnerships and managing emotions and dealing with negative pressures
Age 11-14 - Sexual activity, human reproduction, contraception, pregnancy, STDs including HIV/Aids and high risk behaviours, relationships, including those between old, young, girls, boys and same sex
Age 14-16 - Body image and health, choices relating to sexual activity and substance misuse, and the emotional well-being, reducing risk and minimising harm, parenting skills and family life, separation, divorce and bereavements, prejudice and bullying

Sex education opt out is reduced. BBC News Online, 5 November 2009

Italy: Violence in the lives of women who have an elective abortion

From Women’s Health Issues. 

The authors note that violence is an important health problem for pregnant women, with numerous studies showing that it may compromise maternal and infant health. Many women who seek an elective abortion (EA) live in difficult personal and social circumstances, in which violence often has a central role, yet few studies have analysed the relationships between violence and having an EA.

This study’s objective was to analyse the role of family and partner violence among women seeking an EA, exploring the role of women’s age, and controlling for sociodemographic factors.

An unmatched, case-control study was carried out in the Trieste Public Hospital, including all consecutive EAs (n=445) and live births (n=438). With an anonymous questionnaire, researchers collected information on sociodemographic characteristics, current violence (psychological, physical, and sexual) perpetrated by a partner or by other family members, and past violence.

The results found that compared with postpartum women, EA women were significantly more likely to report any type of current and past violence. Among women younger than 30 years old, adjusting for relevant social factors, partner psychological violence and family violence were strongly associated with EA, whereas among women 30 years old or older, there was no association with partner and family violence after adjustment.

The authors concluded that these results highlight the role of violence in the lives of women, especially younger women, seeking an abortion, and the need for sensitive screening for partner and family violence among these women. Health professionals should be able to recognise violence among women seeking an EA and to support them.

Department of Psychology, University of Trieste, Trieste, Italy. Email:

Violence in the lives of women in Italy who have an elective abortion. Romito P, Escribà-Agüir V, Pomicino L, Lucchetta C, Scrimin F, Molzan Turan J. Women’s Health Issues. 2009 Sep-Oct;19(5):335-43.

UK: Incidence of pregnancy after spontaneous first trimester miscarriage

From the British Medical Journal.

The study set out to compare fertility rates after the three methods of managing early miscarriage in women recruited to the MIST (miscarriage treatment) randomised controlled trial. It was set in early pregnancy clinics of acute hospitals in the south west region of England. The participants were 1199 women who had had an early miscarriage (<13 weeks) confirmed by scan; interventions were expectant, medical, or surgical management. The main outcome measures were self-reported pregnancy rates and live birth rates.

The results found that of 1199 women recruited to the trial, 1128 consented to follow-up. Of these, 762 women replied giving pregnancy details (68% response rate). Respondents were representative of the trial participants. The live birth rate five years after the index miscarriage was similar in the three management groups: 177/224 (79%, 95% confidence interval 73% to 84%) in the expectant management group, 181/230 (79%, 73% to 84%) in the medical group, and 192/235 (82%, 76% to 86%) in the surgical group. There was also no significant difference according to previous birth history. Older women and those with previous miscarriages were significantly less likely to subsequently give birth.

The authors concluded that method of miscarriage management does not affect subsequent pregnancy rates, with around four in five women giving birth within five years of the index miscarriage. Women can be reassured that long term fertility concerns need not affect their choice of miscarriage management.

East Somerset Research Consortium, Westlake Surgery, West Coker, Somerset BA22 9AH. Email

Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial. Smith LF, Ewings PD, Quinlan C. BMJ. 2009 Oct 8;339:b3827. doi: 10.1136/bmj.b3827.

WHO: Use of combined oral contraceptives post abortion

From the journal Contraception.

The authors note that providing combined oral contraceptives (COCs) following surgical or medical induced abortion offers women an opportune moment to initiate a reliable contraceptive method.

They conducted a systematic review, searching MEDLINE and The Cochrane Library for articles in any language concerning COC use following spontaneous, induced (medical or surgical) or septic abortion, from 1966 through June 2008. Seven articles were identified and evaluated using the United States Preventive Services Task Force system.

The results found that immediate COC initiation after first-trimester medical or surgical induced abortion did not increase side effects or prolong vaginal bleeding compared with use of a placebo, copper-bearing intrauterine device (IUD), nonhormonal contraceptive method or COC initiation at a later time. Initiating COCs after first-trimester surgical abortion produced small increases in coagulation parameters compared with IUD use; although they are statistically significant, their clinical relevance is unlikely. No study examined second-trimester induced or spontaneous abortion, or septic abortion.

The authors concluded that evidence shows that COCs can be safely initiated immediately following surgical and medical abortion in the first-trimester of pregnancy.

Department of Reproductive Health and Research, World Health Organisation, Geneva, 27, Switzerland. Email

Use of combined oral contraceptives post abortion. Gaffield ME, Kapp N, Ravi A. Contraception. 2009 Oct;80(4):355-62. Epub 2009 Jun 4.

USA: Impact of individual values on adherence to emergency contraception practice guidelines

From the Archives of Pediatritic and Adolescent Medicine.

The study set out to evaluate the impact of individual, system, and interpersonal factors on emergency contraception practices among pediatric residents. The authors hypothesised that abortion attitudes and attitudes toward teen sex would be significant individual factors influencing emergency contraception practices.

This was a cross-sectional, anonymous Internet survey, set in four pediatric residency programmes in the Baltimore, Maryland-Washington, DC, metropolitan area during April to June 2007. One hundred forty-one pediatric residents completed the survey.

Abortion attitudes were assessed by participants’ level of agreement with abortion in 7 scenarios. Attitudes toward teen sex were assessed by participants’ level of agreement with 5 statements about the acceptability of teens having sex. Emergency contraceptive counselling behaviour was assessed by reported frequency of including emergency contraception in routine contraceptive counselling. Intention to prescribe emergency contraception was assessed by reported likelihood of prescribing in 5 scenarios.

When controlling for demographics and other predictors, residents with less favourable abortion attitudes were more likely to have the lowest intention to prescribe emergency contraception. Residents with more positive attitudes toward teen sex and who had a preceptor encourage emergency contraception prescription were more likely to include emergency contraception in routine contraceptive counseling most/all the time and to have the highest intention to prescribe.

The authors concluded that efforts to challenge and affect attitudes toward teen sex and to prompt residents to prescribe emergency contraception in clinical settings may be needed to encourage more proactive emergency contraceptive practice in accordance with national practice guidelines.

Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. Email

Impact of individual values on adherence to emergency contraception practice guidelines among pediatric residents: implications for training. Upadhya KK, Trent ME, Ellen JM. Archives of Pediatritic and Adolescent Medicine. 2009 Oct;163(10):944-8.

UK: Increasing treatment options for abortion and miscarriage

From the Journal of Family Planning and Reproductive Health Care.

The authors note that there is growing interest in the UK towards increasing treatment options for women undergoing abortion and miscarriage. Such options include home medical treatment and surgery under local anaesthesia (LA).

This study aimed to gauge views of women undergoing abortion and treatment for miscarriage at the Royal Infirmary Edinburgh towards medical treatment at home, and surgery under LA, to determine whether new services should be developed. The study consisted of a self-administered anonymous questionnaire.

The results showed that a total of 148 questionnaires were completed by women undergoing a medical abortion (n = 97; 66%), surgical abortion (n = 30; 20%) or surgical management of miscarriage (n = 21; 14%). Women having an abortion expressed a future preference for medical abortion in hospital (n = 64; 52%) at home (n = 31; 25%) or by surgery under general anaesthesia (GA) (n = 20; 17%) or LA (n = 7; 6%). Women having a miscarriage expressed a future preference for surgery under GA (n = 7; 35%), LA (n = 6; 30%) or medical management at home (n = 4; 20%) or in hospital (n = 3; 15%).

The authors concluded that this study shows that medical abortion at home is a potentially popular choice for women having an abortion, with surgical abortion under LA less so. Both home medical management and surgery under LA would appear to be welcome service developments for women needing treatment for a miscarriage.

University of Edinburgh, Edinburgh, UK.

Women’s preferences for method of abortion and management of miscarriage. Levine K, Cameron ST. Journal of Family Planning and Reproductive Health Care. 2009 Oct;35(4):233-5.

UK: Later motherhood results in rise in Down’s Syndrome pregnancies

The number of Down’s Syndrome pregnancies has risen by more than 70% over the last 20 years, University of London researchers say; but the proportion of terminations has remained constant at 92%.

The sharp rise reflects the growing number of older women becoming pregnant, when there is a higher risk, BBC News Online reports.

The number of Down’s syndrome pregnancies rose from 1,075 diagnoses in 1990 to 1,843 by 2008 in England and Wales. But despite the higher number of Down’s pregnancies, the number of Down’s syndrome babies has fallen by 1%, from 752 to 743.

This is because improved antenatal screening means more Down’s pregnancies are being spotted and more abortions are taking place. Without the improved screening, the number of babies born with Down’s would have risen by 48%, according to the study.

The proportion of couples diagnosed with a Down’s syndrome baby who decided to terminate has remained constant at 92%, say researchers at Queen Mary.

The risk of having a baby with Down’s syndrome is one in 940 for a woman aged 30. But by age 40, the risk rises to one in 85.

Joan Morris, professor of medical statistics at Queen Mary, led the research. She said:

‘What we’re seeing here is a steep rise in pregnancies with Down’s syndrome but that is being offset by improvements in screening. It was thought that these improvements would lead to a decrease in the number of births with Down’s syndrome. However, due to increases in maternal age this has not occurred.’

Professor Morris said the Down’s screening test had become more widely available over the last 20 years.

The report was published in the British Medical Journal. The abstract reads:

‘Despite the number of births in 1989/90 being similar to that in 2007/8, antenatal and postnatal diagnoses of Down’s syndrome increased by 71% (from 1075 in 1989/90 to 1843 in 2007/8). However, numbers of live births with Down’s syndrome fell by 1% (752 to 743; 1.10 to 1.08 per 1000 births) because of antenatal screening and subsequent terminations. In the absence of such screening, numbers of live births with Down’s syndrome would have increased by 48% (from 959 to 1422), since couples are starting families at an older age. Among mothers aged 37 years and older, a consistent 70% of affected pregnancies were diagnosed antenatally. In younger mothers, the proportions of pregnancies diagnosed antenatally increased from 3% to 43% owing to improvements in the availability and sensitivity of screening tests.’

The authors conclude:

‘Since 1989, expansion of and improvements in antenatal screening have offset an increase in Down’s syndrome resulting from rising maternal age. The proportion of antenatal diagnoses has increased most strikingly in younger women, whereas that in older women has stayed relatively constant. This trend suggests that, even with future improvements in screening, a large number of births with Down’s syndrome are still likely, and that monitoring of the numbers of babies born with Down’s syndrome is essential to ensure adequate provision for their needs.’

Carol Boys from the Down’s Syndrome Association said the number of abortions would be reduced if parents were better informed about Down’s syndrome. She said:

‘We realise that tests will continue to become more accurate at increasingly earlier stages of pregnancy. It is therefore even more important that families undergoing the screening process are given non-directive counselling and accurate, up-to-date information about Downs’ syndrome.’

In November 2008, the publication of statistics about the number of live births of children with Down’s Syndrome caused controversy, when it was claimed that an increase in live births was due to Britain becoming a ‘more caring society’.

Steep rise in Down’s pregnancies. BBC News Online, 27 October 2009

Trends in Down’s syndrome live births and antenatal diagnoses in England and Wales from 1989 to 2008: analysis of data from the National Down Syndrome Cytogenetic Register. Joan K Morris, professor of medical statistics, Eva Alberman, emeritus professor. British Medical Journal 2009;339:b3794

Also read:

Comment: Down’s Syndrome, live births, and statistics, by Jennie Bristow. Abortion Review, 26 November 2008

Northern Ireland: SPUC challenges abortion guidelines

A legal challenge to government guidelines on abortion in Northern Ireland has begun at the High Court.

Anti-abortion campaigners want the High Court to quash the current advice which was published in March this year.

The campaigners claim the guidance issued to health professionals is misleading and legally inaccurate. The Society for the Protection of Unborn Children (SPUC) is seeking a High Court declaration that the government guidance does not properly set out the law.

A lawyer for the group told the court on Tuesday that the guidelines contained legal errors, were vague in relation to consent and misrepresented the law in Northern Ireland. He said the result of this was that confusion still remained in such a vital area.

The hearing is due to last two days and it is expected that Lord Justice Girvan will reserve his decision.

During the first stage of its legal battle, lawyers for SPUC claimed the guidance also fails 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. It was also stressed that the document was for health workers rather than the general public.

Anti-abortion group in legal bid. BBC News Online, 27 October 2009

Also read:

Northern Ireland: Official abortion guidance published. Abortion Review, 20 March 2009

UK: New contraceptive statistics released

The condom has now caught up with the pill as women’s usual method of contraception, according to figures issued by the Office for National Statistics.

Condoms are used by 25 per cent of women under 50, and an equal percentage use the pill as a birth-control method, according to Opinions Survey Report No. 41 Contraception and Sexual Health, 2008/09. This is based on information provided by 2,557 respondents (1,464 men and 1,093 women). The findings were released on on 20 October 2009.

Other findings included:

• The majority of women under 50 (75 per cent) were using contraception

• Younger women preferred to use the pill or male condom, and

• Older women were more likely than younger women to rely on sterilisation or their partner’s vasectomy.

Excluding women who had been sterilised at least two years ago, in 2008/09 almost all women (91 per cent) said they had heard of the emergency contraception pill, or ‘morning after pill’. However, awareness of the emergency intrauterine device (IUD), which can be inserted up to five days after intercourse, had fallen from 49 per cent in 2000/01 to 40 per cent in 2008/09.

In 2008/09, TV programmes and adverts were acknowledged as the main source of information about sexually transmitted infections (STIs) by 55 per cent of those surveyed. Newspapers, magazines and books were mentioned as the main source by 16 per cent and government information leaflets by three per cent. Sex information in schools or colleges accounted for 11 per cent.

Over half the men interviewed (59 per cent) who said they were not in a long-term exclusive relationship, but had had a sexual relationship in the last year, admitted that information on HIV and other sexually transmitted infections had no effect on their behaviour. However:

• 34 per cent said they had increased their use of condoms

• Six per cent said they had fewer one-night stands, and

• Six per cent took a test for sexually-transmitted infections when they changed partners.

Around 90 per cent of both men and women who used condoms cited prevention of pregnancy as one of their reasons for using them, and almost half (45 per cent) cited prevention of infection.

Opinions Survey Report No. 41 Contraception and Sexual Health, 2008/09 and further information on Contraception and Sexual Health is available here. 

The Battle for Reproductive Choice

BPAS and the Wellcome Trust are sponsoring a series of debates at the London Battle of Ideas festival on Saturday 31 October.

The Battle for Reproductive Choice

Modern biomedical technology allows us unprecedented levels of control over reproduction. Pre-implantation genetic screening holds out the promise of healthy babies; contraception and abortion allow women to juggle career and family, while infertility treatment offers hope to couples let down by nature. Some though, worry that we should not be playing God or that there are already too many people in the world, and call for regulation. Can people be trusted to make the ‘right choices’? Should it be left to them and their clinicians, or is there a role for official bodies to help them make their choices?

This series of three debates will be held at the Royal College of Art, London, on Saturday 31 October. See here for more information and to book tickets.

Frankenstein’s Daughters: from science fiction to science fact?
10.30am until 12.00pm

Developments in pre-implantation genetic diagnosis and screening (PGD and PGS) allow couples to avoid having children with life-threatening conditions, but they also imply the possibility that some specific forms of disability will be ‘screened out’, raising the prospect of a generation of ‘designer babies’. Many religious groups rail against scientists ‘playing God’. While some disability campaigners fear that the use of PGD and PGS will devalue people born with disabilities, disabled people could potentially use ARTs to select a child that shares their physical impairment: in one high-profile case a deaf couple challenged the assumption that an embryo likely to be deaf should be rejected. Current UK law means ‘normal’ embryos must always be preferred, but is this appropriate given that the state does not prevent two deaf people from becoming parents together ordinarily?

Where does science fact meet science fiction and how can we distinguish between the two outside of the lab? How far should the decisions of HFEA committees regulate individuals’ decision-making and clinicians’ practice? Should the media take a more measured approach to reporting on science and reproduction - or do journalists have a duty to inform us of the worst possible outcomes as well as the most probable? Does pre-implantation genetic screening imply an attack on disabled people? Can biomedical breakthroughs shape what it is to be human?

Speakers:

- Mark Henderson, science editor, The Times (London)
- Ken MacLeod, science fiction writer; writer in residence, ESRC Genomics Policy and Research Forum; author, The Night Sessions
- Sandy Starr, communications officer, Progress Educational Trust
- Dr Alan Thornhill, scientific director, The London Bridge Fertility, Gynaecology and Genetics Centre

Whose Right to Choose? Choice, ethics and regulation in 21st-century reproduction
1.30pm until 3.00pm

In the 20th century, women’s control over their fertility was revolutionised by the contraceptive pill and the growing availability of legal and safe abortion. In the 21st century, reproductive choice is no longer exclusively about preventing or terminating a pregnancy, but also about overcoming natural barriers to conceiving, and choosing to have children using Assisted Reproductive Technologies (ARTs). While contraception and abortion are accepted as a part of modern life, and everybody knows somebody who has experienced fertility treatment, the clash between choice and regulation are still fraught. Policymakers and commentators fret about there being too many abortions, while the media report on fertility treatment allowing women to have babies in their 60s and 70s, octuplets being born in California, and mothers giving birth to their own grandchildren.

Abortion remains a procedure that cannot be accessed ‘on demand’ – a woman must claim that having a child will damage her mental health, and two doctors must authorise the procedure. Fertility treatment is subject to myriad regulations by the Human Fertilisation and Embryology Authority. Recent guidance about Single Embryo Transfer, which limits the ability of clinics to implant more than one embryo at a time, so as to reduce the likelihood of complications, has been opposed by some women and doctors, who see this as a restriction on their ability to make personal and clinical judgements.

Should we trust people to make the right reproductive choices – or do we need to protect them against the excesses of what is possible? Are there ‘too many abortions’ – or too many people seeking fertility treatment for the wrong reasons? How far should the decisions of official bodies regulate individuals’ decision-making and clinicians’ practice?

Speakers:

- Professor Peter Braude, head of department, Women’s Health, King’s College London; director, Centre for Preimplantation Genetic Diagnosis, Guy’s and St Thomas Hospital
- Ann Furedi, chief executive, BPAS
- Professor Sally Sheldon, professor of law, Kent Law School, University of Kent; co-author, Fragmenting Fatherhood: a socio-legal study

Three’s a Crowd? The battle over population and reproduction
3.30pm until 5.00pm

A high-profile campaign by the Optimum Population Trust, supported by such luminaries as government advisor Jonathon Porritt and broadcaster David Attenborough, seeks to encourage couples worldwide to limit their families to two children. The ‘Stop At Two’ campaign is premised on the idea that unrestrained population growth will damage the environment. But some argue that fears about the environmental effects of population growth represent a new form of Malthusianism, the old idea that population growth will push society up against natural limits.

Critics of the ‘Stop At Two’ campaign point out that Malthusianism was discredited by historical developments, and suggest the same will be true of today’s fears. They argue that we can tackle environmental problems without limiting the world population, and that ‘reproductive choice’ should mean people make decisions about having children based on their own desires and circumstances. Some worry that Western NGOs campaigning for contraception and sex education in the developing world under the banner of women’s rights are in fact promoting a Malthusian agenda, pointing to the repressive history of state population control programmes. But sympathisers with the ‘Stop At Two’ campaign stress this is about individuals making choices; and what is wrong with encouraging them to take the environment into account?

Where does ‘family planning’ stop being about individuals and couples making their own reproductive decisions and become a moral imperative that people should make the ‘right choices’? Are fears about population growth a new form of an old panic, or is the expanding carbon footprint a problem we need to address by limiting population growth? What circumstances and concerns do people take into account when they plan their families today?

Speakers:

- Dr Austen Ivereigh, Catholic commentator; lead organiser, West London Citizens; former press and policy advisor to the Archbishop of Westminster
- Dr Ellie Lee, lecturer in social policy, University of Kent; co-ordinator of Pro-Choice Forum
- Adrian Stott, principal, Enable Solutions; trustee, Optimum Population Trust
- Mark Walport, director, Wellcome Trust; formerly professor of medicine, Imperial College London

See here for more information and to book tickets.

UK: Statistics on community contraceptive services

The report NHS Contraception Services, England: 2008-09 has been published. 

This data has been collected annually since 1988/89 through the KT31 return, which includes services provided by trusts in NHS clinics and as domiciliary visits, and Brook.

Information on NHS community contraception excludes services provided in out-patient clinics and those provided by General Practitioners. Limited data is presented for out-patient clinics sourced from The NHS Information Centre’s (NHS IC) Hospital Episode Statistics (HES), prescription data from the Prescribing Support Unit (PSU) and survey data from ‘Contraception and Sexual Health 2008/09’, a report published by the Office for National Statistics (ONS) on behalf of the NHS Information Centre. This is a sample survey of women aged 16 to 49 and men aged 16 to 69 in Great Britain, and gives an overview of all contraception used irrespective of whether it is provided by the NHS. It also asks about sexual behaviour and knowledge of sexually transmitted infections.

Key facts

* There were 2.5 million attendances at NHS community contraceptive clinics made by 1.3 million individuals. This represented an increase of 3 per cent (62,000) on the number of attendances in 2007/08 (also 2.5 million) and an increase of 7 per cent (84,000) on the number of individuals in 2007/08 (1.2 million). In spite of these latest increases, overall, the number of attendances and the number of individuals has remained broadly stable over the last 10 years.

* 140,000 men attended NHS community contraceptive clinics, an increase of 13 per cent (17,000) on 2007/08 (123,000) and the third consecutive annual increase.

* Among women who attended NHS community contraceptive clinics, the 16-19 year old age group had the highest number of attendances per 100 population. An estimated 21 per cent of women in this age group visited a clinic during the year while the equivalent proportion for those aged 13 to 15 was 8 per cent. In 2007/08 the respective proportions for these age groups were 20 per cent and 8 per cent.

* Oral contraception was the primary contraceptive method of 44 per cent of women who attended NHS community contraceptive clinics, and it remains the most common primary method. This percentage has remained stable since 2003/04.

* Use of Long Acting Reversible Contraceptives (LARCs) continues to increase and now accounts for 24 per cent of primary methods of contraception among women who attended NHS community contraceptive clinics. This percentage was 23 per cent in 2007/08 and 18 per cent in 2003/04.

NHS Contraception Services, England: 2008-09. NHS Information Centre, 20 October 2009

UK: DFID publishes policy position on safe and unsafe abortion

Safe abortion is a right and a necessity, says the Department for International Development. 

The policy position, published in October 2009, is summarised as follows:

DFID supports safe abortion on two grounds. First, it is a right. Women have the right to reproductive health choices. Second, it is necessary. 20% of pregnancies globally end in induced abortion; unsafe abortion accounts for 13% of all maternal deaths and the hospitalisation of a further five million women every year due to serious health complications. This preventable mortality and ill-health due to unsafe abortion is seriously undermining countries’ ability to achieve MDG 5 (to improve maternal health) and places a high burden on already over-stretched health systems. But DFID does not support abortion as a method of family planning. In countries where it is legal, DFID will support programmes that make safe abortion more accessible. In countries where it is illegal and mortality and morbidity is high, DFID will make the consequences of unsafe abortion more widely understood, and will consider supporting processes of legal and policy reform.

The full document is available here.

Commentary: Writing in the Belfast Telegraph on 22 October 2009, Eamonn McCann asks, ‘Why have we one rule for abortion in Lusaka and another in Lisburn?’

‘The Government of which [International Development Minister] Mike Foster is a member refuses to consider intervention to assert the same right and meet the same necessity in a region which remains constitutionally part of the UK, while advocating safer and more accessible abortions in Africa, Latin America, south Asia and other far-flung places where the UK has no jurisdiction,’ argues McCann.

Read the full article here.

Mexico: The evolution of Mexico City’s abortion laws

From International Journal of Gynaecology and Obstetrics.

The author notes that before 2000, Mexico City’s criminal laws prohibited induced abortion to maintain public morality. The Criminal Code considered abortion by accident or in cases of rape not criminal, and criminal but excusable - and therefore not punishable - in certain cases not endangering public morality, such as medical necessity to save the woman’s life.

In 2000, the Criminal Code was reformed expanding exceptions from criminal liability, particularly in cases of danger to a woman’s health or where fetal survival was at risk.

In 2004, Mexico City enacted its own law, effectively decriminalising consensual abortion in cases of rape, fetal malformation, and risk to the woman’s health.

A 2007 reform further decriminalised all consensual abortion within the first 12 weeks of pregnancy, and required public hospitals to provide abortion and family planning services. In August 2008, the Supreme Court of Mexico ruled Mexico City’s 2007 liberalisation of abortion law constitutional.

Centro de Investigación y Docencia Económicas, Mexico City, Mexico. Email:

The evolution of Mexico City’s abortion laws: from public morality to women’s autonomy. Madrazo A. International Journal of Gynaecology and Obstetrics. 2009 Sep;106(3):266-9. Epub 2009 Jul 9.

USA: Statement on family planning following abortion

USAID and key health oganisations have signed a consensus statement on family planning as a key component of post abortion care. 

The United States Agency for International Development (USAID), together with the International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM), and the International Council of Nurses (ICN), has issued a consensus statement about the importance of family planning as a key component of post abortion care. 

The policy statement underscores the commitment of these organisations to ensuring their members advocate for high-quality post abortion family planning counselling and services, Reuters reports.  It is expected to set the standard for all post abortion care and will bring improvements to both family planning and maternal health care.

‘Universal access to post abortion and postpartum family planning makes good sense,’ said Dr. Scott Radloff, director of USAID’s Office of Population/Reproductive Health. ‘It must be considered as an important element of our care based on the clear evidence that family planning and pregnancy spacing not only reduce unintended pregnancies and the need for abortion but also lower morbidity and mortality of women, neonates, infants, and children.  Post abortion care is essential to good obstetric care and is an important element in integrated family planning/maternal and child health services for women.’

Despite the high death toll from complications from abortion - unsafe abortion accounts for 13 percent of maternal deaths worldwide and as much as 25 percent in some countries, and some 31 million women have spontaneous abortions each year - many women do not receive immediate post abortion family planning services, even though they are at risk of pregnancy within two to three weeks, Reuters reports. While many of these women desire to replace the pregnancy they have lost, health experts recommend birth spacing of six months after a spontaneous abortion for optimal pregnancy outcomes.

The consensus statement notes that all women should receive counseling and family planning services after any abortion - spontaneous or induced - irrespective of the pregnancy termination or evacuation procedure used. When family planning counselling and services are offered after all types of post abortion treatment, acceptance is high.

Among the key consensus points:

* Unmet need for family planning is a primary cause of induced abortion
* All post abortion women should receive voluntary post abortion family planning counselling
* A wide range of contraceptive methods, including long-acting methods, should be offered and accompanied by simple written instructions
* Post abortion family planning uptake is high when quality services are offered before a woman is discharged from the hospital or clinic
* Provision of universal access to post abortion family planning should be a standard of practice for doctors, nurses, and midwives.

USAID and Key Health Organizations Sign Consensus Statement on Family Planning as a Key Component of Post Abortion Care. Reuters, 22 October 2009

Peru: Abortion bill prompts protests in capital

Hundreds of people have demonstrated in Lima as a legislative panel approved a bill proposing legalising abortion in some cases.

The bill, which proposes allowing abortion in cases of rape, incest or fetal abnormality, will now be sent to Congress for debate, BBC News Online reports. Supporters and opponents of the bill shouted slogans and scuffled with police outside the Congress building.

Abortion is currently illegal in Peru unless the mother’s life is in danger.

The BBC’s Dan Collyns in Lima said passions were running high in the capital over the extremely contentious issue. The rival demonstrations, mostly made up of women, were hemmed in by riot police as they chanted slogans and waved placards.

‘The basic human right of deciding about our bodies is not given by the state,’ said one women protesting in favour of the bill. ‘As citizens - as women that are citizens - we are asking Congress to really talk about this and really think about the women, not about the religious ideologies or the conservative ideologies.’

Another protester, Lisette Roman, told the Associated Press women were ‘dying everyday while getting clandestine abortions’.

The proposal has been strongly opposed by the Catholic Church in Peru under Cardinal Juan Luis Cipriani, who has described it as a ‘death penalty’.

‘God has created everyone in his image and likeness and all of us have the right to exist,’ said one man protesting outside Congress. ‘So God has a purpose for every child.’

Another Catholic protester, Leoncio Castro, said he was ‘defending life’ by opposing the bill.

Rights groups say that more than 370,000 illegal abortions are carried out in Peru each year, but anti-abortion activists reject that figure. A recent poll showed that just over half of Peru’s population opposed extending the law.

Clashes over Peru abortion move. BBC News Online, 21 October 2009

‘Abortion Worldwide: A decade of uneven progress’

Restricting the availability of legal abortion does not appear to reduce the number of women trying to end unwanted pregnancies, a major report by the Guttmacher Institute suggests.

The survey found abortion occurs at roughly equal rates in regions where it is legal and regions where it is highly restricted.

It did note that improved access to contraception had cut the overall abortion rate over the last decade. But unsafe abortions, primarily illegal, have remained almost static, BBC News Online reports.

The survey of 197 countries carried out by the Guttmacher Institute - a pro-choice reproductive think tank - found there were 41.6m abortions in 2003, compared with 45.5 in 1995 - a drop which occurred despite population increases.

Nineteen countries had liberalised their abortion laws over the 10 years studied, compared with tighter restrictions in just three. But despite the general trend towards liberalisation, some 40% of the world’s women live amid tight restrictions. On some continents this is particularly pronounced: well over 90% of women in South America and Africa live in areas with strict abortion laws, proportions which have barely shifted in a decade.

Researchers also noted that while liberalisation was a key element in improving women’s access to safer terminations, it was far from the only factor. Even in countries where abortion is legal, lack of availability and cost may prove major obstacles. In India for example, where terminations are legally allowed for a variety of reasons, some 6m take place outside the health service.

The costs of unsafe abortions, which can include inserting pouches containing arsenic to back street surgery, can be high: the healthcare bill to deal with conditions from sepsis to organ failure can be four times what it costs to provide family planning services.

Every year, according to the report, an estimated 70,000 women die as a result of unsafe abortions - leaving nearly a quarter of a million children without a mother - and 5 million develop complications.

In the developed world, legal restrictions did not stop abortion but just meant it was ‘exported’, with Irish women for instance simply travelling to other parts of Europe, according to Guttmacher’s director, Dr Sharon Camp. In the developing world, it meant lives were put at risk.

‘Too many women are maimed or killed each year because they lack legal abortion access,’ she said. ‘The gains we’ve seen are modest in relation to what we can achieve. Investing in family planning is essential - far too many women lack access to contraception, putting them at risk.’

Western Europe is held up as an example of what access to contraceptive services can achieve, and the Netherlands - with just 10 abortions per 1,000 women compared to the world’s 29 per 1,000 - is held up as the gold standard. Here, young people report using two forms of contraception as standard.

Even the UK, which has a relatively high rate, fares well in comparison to the USA, where the number of abortions is among the highest in the developed world. The institute says this rate is in part explained by inconsistencies in insurance coverage of contraceptive supplies.

In much of eastern Europe, where abortion was treated as a form of birth control, abortion rates have dropped by 50% in the past decade as contraceptives have become more widely available. And globally, the number of married women of childbearing age with access to contraception has increased from 54% in 1990 to 63% in 2003, with gains also seen among single, sexually active women.

But there were still significant unmet contraception needs, and a lack of interest among pharmaceutical companies in developing new forms of birth control that provide top protection on demand, the institute said.

Bans ‘do not cut abortion rate’. BBC News Online, 13 October 2009

Abortion Worldwide: A Decade of Uneven Progress. Guttmacher Institute, October 2009 [.pdf]

Also read:

New Data on Global Abortion Trends: Implications for U.S. Policy. By Susan Cohen, Guttmacher Institute. RH Reality Check, 15 October 2009

Guttmacher Responds to Critics of Global Abortion Study. By Susan Cohen, Guttmacher Institute. RH Reality Check, 20 October 2009

Is abortion killing 70,000 women a year? Yes, no, maybe. By Ed West. Daily Telegraph blog, 15 October 2009

UK: Government ordered to publish late abortion stats

The Department of Health has been told to publish full data about the number of abortions carried out because of fetal abnormality.

The ruling was made by the Information Commissioner on 15 October. Ministers have been told to release the data for England and Wales within the next month.

This is the latest stage in a complex legal battle which began six years ago, BBC News Online reports. Often referred to as the ‘Jepson case’, the issue burst into the public arena in 2002-3, when Joanna Jepson, a photogenic curate who had had a congenital malformation of the jaw corrected, succeeded in bringing a judicial review of a case in which a woman had aborted a fetus with a cleft palate after 24 weeks. It is legal to terminate a pregnancy up to birth if there is a serious risk of physical or mental abnormality.

Anti-abortion campaigners uncovered the ‘abortion for cleft palate’ case from official statistics, and the furore led to one of the doctors involved in the case being identified. The Crown Prosecution Service eventually decided that there was no evidence on which to base a prosecution. However, because of this case, in 2003 the Department of Health (DH) stopped publishing full statistical data on abortions due to fetal abnormality after 24 weeks of pregnancy, meaning it is not always possible to detect how many abortions can be attributed to a particular disability.

Lawyers for the DH had argued that the information was ‘sensitive, personal and private’. But the Information Tribunal said it was satisfied that the likelihood of a doctor being identified from the statistics alone ‘is so remote that disclosure of the disputed information would not be unwarranted’. And the ruling said it was ‘very unlikely’ that a patient would be identified.

The Pro Life Alliance, which has pursued the challenge, said:

‘This is a straightforward judgement which maintains the principles that statistics do not constitute personal data, that abortion is a serious procedure and that transparency is necessary to satisfy legitimate public interest in this controversial medical practice.’

In a joint statement, Brook and fpa (Family Planning Association) said:

‘We are dismayed by this decision. Whatever anti-choice groups aim is in seeking the data to be released, the potential for individual women and doctors carrying out the procedure to be identified is deeply worrying and unethical. We strongly encourage Department of Health to challenge this decision in the High court for the sake of the few vulnerable women that will be affected.’

Jane Fisher, director of Antenatal Results and Choices, which helps women whose babies are diagnosed with congenital abnormalities in the womb and gave evidence for the DHt the tribunal, said her concern was primarily about the confidentiality of the women.

‘We know full well how agonising it is at that late stage,’ she said. ‘We are protective of the confidentiality of them and of clinicians. They take their responsibilities really seriously. The fallout from the Jepson case was that clinicians were even more cautious about offering terminations [for fetal malformations after 24 weeks] because of the possibility of come-back.’

Ann Furedi, chief executive of BPAS, said:

‘I believe it’s better to have this information in the public domain, and to take measures to protect the confidentiality of patients and doctors. Abortion providers have nothing to hide, or be ashamed of. In fact, the statistics about abortion for fetal abnormality illustrate how serious the cases are and how desperate the parents terminating the pregnancy must be. Even the Jepson case led to a discussion about how serious an abnormality cleft palate can be. ‘

Furedi rejected concerns that abortion doctors would be targeted as a result of this ruling, pointing out that the situation in Britain is very different to that in the USA. ‘Doctors were not targeted as a direct result of the publication of these statistics even when they were published,’ she said. ‘In the Jepson case, the hunt for the doctors involved was not an inevitable consequence of the publication of the stats - it was the result of the anti-choice lobby whipping up a story.’

The Department of Health said it would consider the implications of the judgement and whether to lodge an appeal with the High Court.

Late abortions data to be public. BBC News Online, 15 October 2009
BBC Health Correspondent

Confidentiality fear over late abortion data. Guardian, 16 October 2009

Also read:

Listen to Ann Furedi debating this issue with the Pro Life Alliance on Radio Four Woman’s Hour, 23 October 2009

Free fetal DNA testing: Implications for the abortion debate. Abortion Review, 6 November 2008

Anti-abortion group in statistics fight. Abortion Review, 29 May 2009

Doctor found guilty of drink spiking to cause abortion

A jury has found Edward Erin guilty of attempting to poison his lover in a bid to induce an abortion.

Dr Edward Erin, 44, of west London, spiked the drinks of Bella Prowse, 33, after she became pregnant but refused a termination, the Old Bailey heard. Miss Prowse gave birth to a healthy baby in September 2008.

The married father-of-two, who worked at St Mary’s Hospital in Paddington, west London, had denied attempting to administer poison to cause a miscarriage, BBC News Online reports.

The jury found Erin guilty of two charges of attempting to administer poison - once in a cup of coffee from Starbucks and then in a glass of orange juice. The court had been told tests showed traces of the drug in both Miss Prowse’s body and a cup given to her by Erin.

But Erin was found not guilty on another charge of spiking a cup of tea given to Miss Prowse as the jury could not reach a decision.

The Crown Prosecution Service will decide next week whether to seek a retrial on that charge.

Judge Richard Hone told Erin: ‘A custodial sentence is virtually inevitable.’

Det Ch Insp Mickey Gallagher said: ‘This case is only the second of its type to be brought before the courts in 40 years.’

Erin, originally from Caerphilly, south Wales, was banned from working with patients by the General Medical Council pending the verdict.

The wealthy doctor, who also owns a property company, began his affair with Miss Prowse at a Christmas party in 2007. When she fell pregnant the doctor begged her to have an abortion, claiming if she had the baby it would ‘kill him and he would have to leave work’. She became suspicious after allegedly finding yellow powder in a cup of Earl Grey tea Dr Erin made for her in January 2008.

Poison abortion bid doctor guilty. BBC News Online, 19 October 2009

Spain: Demonstrations against abortion law reform

More than a million people are said to have taken part in a march in Madrid to oppose government plans to liberalise Spain’s abortion law.

Several dozen centre-right opposition party joined the demonstration, which was backed by Roman Catholic bishops, BBC News Online reports.

Socialist Prime Minister Jose Luis Rodriguez Zapatero wants abortion to be to available to all women up until the 14th week of pregnancy. At present, a pregnancy can only be terminated in mainly Catholic Spain under specific circumstances. The draft law currently before parliament would also permit girls aged 16 and 17 to have an abortion without their parents’ knowledge.

It is the latest in a series of ethical issues which have pitted the Catholic right against the government, which has legalised gay marriage and made divorce easier, the BBC reports.

Police estimates put the crowd at 250,000, but the regional government said that over a million had turned out, with the organisers claiming a turnout of two million. The march brought together more than 40 religious and civil society groups calling for the government to withdraw the draft bill.

‘This new law is a barbarity,’ said one protester, Jose Carlos Felicidad, from the southern town of Algeciras. ‘In this country, they protect animals more than human beings,’ he told AFP news agency.

A broad cross-section of Spanish society were represented, says the BBC’s Steve Kingstone in Madrid - old and young, parents with babies, priests, nuns, immigrant families and organised groups coached in from all over the country. They gathered in the heart of Madrid under an enormous blue banner the height of a two-storey building emblazoned with the simple message: ‘Every life matters.’

Spain’s existing law, dating from 1985, allows abortion in cases of rape and when there are signs of fetal abnormality. Spanish women can also end a pregnancy if their physical or psychological health is at risk. In practice, the last category has been used to justify the vast majority of abortions - of which there were 112,000 in 2007.

The government says the new law is about respect and rights for women, and that anyone wanting to terminate a pregnancy will first be explained the alternatives - including state help for young mothers. It also claims its proposal will make abortion safer - by ensuring the procedure does not happen beyond 22 weeks of a pregnancy.

Big anti-abortion rally in Spain. BBC News Online, 17 October 2009

Also read:

Spain: Plans for abortion on demand in first trimester Abortion Review 28 September 2009

Spain: Progress reported in abortion law reform Abortion Review 22 September 2009

Spain: Legal reform on the cards Abortion Review 15 May 2009

Spain: Church and state clash over abortion law reform Abortion Review 17 March 2009

UK: The role of feticide in the context of late abortion - health professionals’ and parents’ views

From Prenatal Diagnosis. 

The study set out to provide an in-depth account of the role feticide has relative to experiences of late termination of pregnancy (TOP).

This was an exploratory qualitative interview study. Participants were recruited from three National Health Service (NHS) units that provide secondary and tertiary level fetal medicine services. Data were collected from 36 in-depth interviews, with 12 parents (representing eight cases) who had experienced late TOP for fetal anomaly and 23 health professionals with experience of feticide provision. The qualitative analysis utilised a generative thematic approach, facilitated by Atlas.ti qualitative software package.

Two key themes from the study provide data on how perceptions of feticide were described by those involved in late TOP: (1) feticide is recognised and described as a legitimate clinical procedure and (2) the practice of feticide is conceptualised as difficult but necessary.

The authors concluded that for health professionals who provide and facilitate feticide, and for parents making decisions about late TOP and feticide, the procedure is understood as a necessary rather than chosen activity. Parents’ perceptions of feticide may differ, and good clinical care must be designed to cope with this variation. For health professionals, feticide seems more readily distinguished from other types of TOP activities and may evoke simultaneous positive and negative perceptions.

School of Geography, Politics and Sociology (Sociology), Newcastle University, Newcastle upon Tyne, NE1 7RU, England, UK. Email:

The role of feticide in the context of late termination of pregnancy: a qualitative study of health professionals’ and parents’ views. Graham RH, Mason K, Rankin J, Robson SC. Prenatal Diagnosis. 2009 Sep;29(9):875-81.

USA: Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 days

From Contraception. 

From 2001 to March 2006, Planned Parenthood Federation of America (Planned Parenthood) health centres throughout the United States provided medical abortions principally by a regimen of oral mifepristone, followed 24-48 h later by vaginal misoprostol. In late March 2006, analyses of serious uterine infections following medical abortions led Planned Parenthood to change the route of misoprostol administration and to employ additional measures to minimise subsequent serious uterine infections.

In August 2006, the authors conducted an extensive audit of medical abortions with the new buccal misoprostol regimen so that patients could be given accurate information about the success rate of the new regimen. They sought to evaluate the effectiveness of the buccal medical abortion regimen and to examine correlates of its success during routine service delivery.

In 2006, audits were conducted in 10 large urban service points to estimate the success rates of the buccal regimen. Success was defined as medical abortion without vacuum aspiration. These audits also permitted estimates of success rates with oral misoprostol following mifepristone in a subset in which 98% of the subjects stemmed from two sites.

The effectiveness of the buccal misoprostol-mifepristone regimen was 98.3% for women with gestational ages below 60 days. The oral misoprostol-mifepristone regimen, used by 278 women with a gestational age below 50 days, had a success rate of 96.8%.

The authors concluded that in conjunction with 200 mg of mifepristone, use of 800 mcg of buccal misoprostol up to 59 days of gestation is as effective as the use of 800 mcg of vaginal misoprostol up to 63 days of gestation.

Planned Parenthood Federation of America, New York, NY 10001, USA. Email:

Effectiveness of medical abortion with mifepristone and buccal misoprostol through 59 gestational days. Fjerstad M, Sivin I, Lichtenberg ES, Trussell J, Cleland K, Cullins V. Contraception. 2009 Sep;80(3):282-6. Epub 2009 May 2.

USA: Physicians’ beliefs about conscience in medicine

From Academic Medicine.

The study set out to explore physicians’ beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians’ opinions and their religious and ethical commitments.

A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. Participants were classified into three groups according to agreement or disagreement with two statements: ‘A physician should never do what he or she believes is morally wrong, no matter what experts say,’ and ‘Sometimes physicians have a professional ethical obligation to provide medical services even if they personally believe it would be morally wrong to do so.’

The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2-7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong.

The authors concluded that a substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.

Pritzker School of Medicine, University of Chicago, Chicago, Illinois 60637-5415, USA. Email:

Physicians’ beliefs about conscience in medicine: a national survey. Lawrence RE, Curlin FA. Academic Medicine. 2009 Sep;84(9):1276-82.

Canada: Women’s views regarding hypnosis for the control of surgical pain

From Journal of Women’s Health. 

The aim of this study was to assess women’s satisfaction with a hypnotic intervention for anxiety and pain management during a pregnancy-terminating procedure.

Women (N = 350) scheduled for first-trimester surgical abortion were randomly assigned to standard care or to a short, standardised hypno-analgesia intervention before and during the procedure. Researchers assessed their individual use of the various hypnotic strategies proposed during the intervention and their views (likes/dislikes) about the hypnotic intervention, the pregnancy termination experience, and their participation in this randomised study.

Mental imagery of a secure place was the strategy used by most women (71%) in the hypnosis group, but a significant proportion of them also used dissociation (42%) and focal analgesia (39%). Advantages of hypnosis over standard care were found in the patients’ report that they could resume their normal activities right after being discharged from the hospital (72% in hypnosis vs. 56% in control group) and in their appreciation of the accompaniment (hypnotherapist vs. nurse) provided during the procedure (97% in hypnosis vs. 56% in control group). Among those who received hypnosis, 97% affirmed that they would recommend hypnosis to a friend for a similar procedure. More than 98% in both groups indicated they would again volunteer to participate in a study evaluating hypnosis for pain management.

The authors concluded that women in the hypnosis group generally reported higher levels of satisfaction with various aspects of the procedure. This is consistent with the growing literature in favour of hypnotic interventions to improve pain management and care.

Department of Pediatrics, Centre Hospitalier Universitaire de l’Universite Laval, Université Laval, Quebec, Canada. Email:

Women’s views regarding hypnosis for the control of surgical pain in the context of a randomized clinical trial. Marc I, Rainville P, Masse B, Dufresne A, Verreault R, Vaillancourt L, Dodin S. Journal of Women’s Health (Larchmt). 2009 Sep;18(9):1441-7.

UK: Late abortion - a comparison of obstetricians’ experience in eight European countries

From BJOG.

The study set out to compare the experience and attitude of obstetricians in Europe towards late termination of pregnancy and the factors affecting their responses.

This was a cluster sampling cross-sectional survey. All neonatal intensive care unit (NICU)-associated maternity units were recruited (census sampling) in Luxembourg, the Netherlands and Sweden. In France, Germany, Italy, Spain and the UK, units were selected at random. In every recruited unit, all obstetricians with at least 6 months’ experience were invited to participate. The setting was ICU-associated maternity units in eight European countries; the population was obstetricians with at least 6 months’ clinical experience.

An anonymous, self-administered questionnaire was used. Multinomial logistic analysis was used to identify factors predicting the obstetricians’ views about modifying the law governing late termination in their country. The main outcome measure was obstetricians’ experience of late termination of pregnancy and views about national policies.

One hundred and five units and 1530 obstetricians participated (response rates 70 and 77% respectively). The most common indications for late termination were congenital anomalies and women’s physical health. Feticide was not common except in France, Luxembourg and the UK. Active euthanasia of a liveborn was practised in France and the Netherlands. Obstetricians in Germany were more likely to feel that late termination should be more severely restricted, the opposite was true in Spain and the Netherlands. In Italy, there was dissatisfaction with current status, but opinion was divided, reflecting views on both sides of the debate.

The authors concluded that this research outlines current practice in a difficult and sensitive area and suggests the need for more discussion and support for all those who were involved.

Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK. Email:

Late termination of pregnancy: a comparison of obstetricians’ experience in eight European countries. Habiba M, Da Frè M, Taylor DJ, Arnaud C, Bleker O, Lingman G, Gomez MM, Gratia P, Heyl W, Viafora C; EUROBS Study Group. BJOG. 2009 Sep;116(10):1340-9. Epub 2009 Jun 3.

USA: Unexpected heaping in reported gestational age for women undergoing medical abortion

From Contraception. 

In August 2006, the Planned Parenthood Federation of America (Planned Parenthood) conducted an extensive audit of first-trimester medical abortions with oral mifepristone plus buccal misoprostol through 56 days of gestation so that patients could be given accurate information about the success rate of the new regimen.

The authors sought to evaluate the effectiveness of this buccal misoprostol regimen and to examine correlates of its success during routine service delivery.

Audits in 10 large urban service points were conducted in 2006 to estimate the success rates of the buccal regimen. Success was defined as medical abortion without vacuum aspiration. The resuts found unexpected heaping of reported gestational age (GA) on days divisible by 7.

The authors concluded that such heaping, which has not been reported in the literature, would make it more difficult to detect a modest trend in declining effectiveness with increasing GA, if there were one. High coefficients of variation of sac size and crown-rump length characterise the early gestational weeks.

The authors suspect, but are unable to prove, that the source of the heaping found in their investigation is a tendency for operators of ultrasound machines at some sites to simplify reporting by rounding a portion of the results to a date corresponding to the nearest complete gestational week. They believe that immediate supervisory awareness and feedback may reduce the extent of the problem. However, the problem may persist in multiple-site studies given the underlying variability of ultrasound measurements with differently calibrated machines and different rules for recording data, some of which may permit acceptance of an estimate based on the stated date of the last menses, if it differs by no more than 2 or 3 days from the ultrasound result.

Reproductive Health Program, Population Council, New York, NY 10065, USA. Email:

Unexpected heaping in reported gestational age for women undergoing medical abortion. Sivin I, Trussell J, Lichtenberg ES, Fjerstad M, Cleland K, Cullins V. Contraception. 2009 Sep;80(3):287-91. Epub 2009 May 9.

France: World collaborative report on Assisted Reproductive Technology, 2002

From Human Reproduction. 

The International Committee for Monitoring Assisted Reproductive Technology’s (ICMART) Eighth World Report analyses assisted reproductive technology (ART) practice and results for the year 2002 from 53 countries by type of ART, women’s age, number of embryos transferred and multiple births.

Over 601,243 initiated cycles resulted in a delivery rate (DR) per aspiration of 22.4% for conventional IVF, 21.2% for ICSI and a DR per transfer of 15.3% for frozen embryo transfer. For conventional IVF and ICSI, there was an overall twin rate of 25.7% per delivery and a triplet rate of 2.5%.

The number of babies born worldwide through ART in 2002 was estimated to range between 219,000 and 246,000. There were wide variations in availability, DRs and multiple birth rates across the countries.

Compared with the previous report (year 2000), there was a large increase in the number of cycles and a slight increase in the DR. There was a marginal decline in the mean number of embryos transferred and in the multiple DRs.

INSERM U822, Hôpital de Bicêtre, 82 rue du Général Leclerc, 94276 Le Kremlin Bicêtre Cedex, Paris, France.

World collaborative report on Assisted Reproductive Technology, 2002. International Committee for Monitoring Assisted Reproductive Technology, de Mouzon J, Lancaster P, Nygren KG, Sullivan E, Zegers-Hochschild F, Mansour R, Ishihara O, Adamson D.  Human Reproduction. 2009 Sep;24(9):2310-20. Epub 2009 May 27.

Norway: Antenatal ultrasound and postnatal autopsy findings in abortion for fetal abnormality

From Acta Radiologica.

The authors note that ultrasound screening has been part of antenatal care for several decades, and warrants high expertise to meet the criteria for a worthwhile screening programme. In particular, the rate of false positives should be low.

The study’s purpose was to examine time trends of pregnancy terminations for fetal abnormality after 12 weeks’ gestation, and to assess the agreement between antenatal ultrasound and post-termination autopsy findings for the main pathologies leading to termination.

During the period 1988 to 2002, 198 pregnancies were terminated for fetal abnormality after 12 weeks’ gestation. Researchers reviewed the case notes for those 151 who were autopsied (male/female/undetermined ;= ;91/56/4). Annual rates of live births and stillbirths were retrieved from the Medical Birth Registry of Norway.

Antenatal ultrasound provided a correct diagnosis of the major abnormality in 149/151 cases (99%), based on post-termination autopsy findings. The annual rate of terminations after 12 weeks’ gestation varied between 0.6 and 3.4 (mean 1.8) per 1000 live births, with a trend toward higher rates over the study period (P=0.001, chi-square test for linear-by-linear association).

The authors concluded that the specificity of antenatal ultrasound for major abnormalities was high, as compared to postnatal autopsy findings. The mean annual rates of termination after 12 weeks’ gestation tended to increase over the 14-year study period.

Department of Radiology, Haukeland University Hospital, Bergen, Norway.

Antenatal ultrasound and postnatal autopsy findings in terminations after 12 weeks’ gestation due to fetal abnormality: population-based study in Western Norway, 1988-2002. Parkar AP, Olsen ØE, Maartmann-Moe H, Daltveit AK, Gjelland K, Rosendahl K. Acta Radiologica. 2009 Sep;50(7):816-22.

Australia: Optimisation of third-stage management after second-trimester medical abortion

From the American Journal of Obstetrics and Gynecology.

The study compared 3 regimens for third-stage management after second-trimester intravaginal misoprostol termination. This was a prospective randomized trial. Three third-stage management strategies were compared: 10 units of intramuscular oxytocin (group 1), 600 microg oral misoprostol (group 2), or no additional medication (group 3) after fetal expulsion. Primary study outcome was the incidence of placental retention.

Two hundred fifty-one women were randomly assigned to the groups. There was a significant difference in placental retention rates: group 1, 8 of 83 (10%) vs group 2, 24 of 83 (29%) vs group 3, 26 of 85 (31%); P = .002. Blood loss was significantly lower in group 1, 100 mL (interquartile ranges, 50-200) vs group 2, 200 mL (interquartile ranges, 100-370) vs group 3, 200 mL (interquartile ranges, 100-375); P < .001. Requirement for blood transfusion: group 1, 1 of 83 (1%) vs group 2, 1 of 83 (1%) vs group 3, 5 of 85 (6%); P = .103.

The authors concluded that intramuscular oxytocin administered after fetal delivery after second-trimester medical termination significantly increases placental expulsion rates and decreases short-term postpartum blood loss.

School of Women’s and Infants’ Health, The University of Western Australia, and The Women and Infants’ Research Foundation, Perth, Western Australia.

Optimization of third-stage management after second-trimester medical pregnancy termination. Dickinson JE, Doherty DA. American Journal of Obstetrics and Gynecology. 2009 Sep;201(3):303.e1-7. Epub 2009 Jul 26.

Turkey: Vaginal versus sublingual misoprostol for second-trimester abortion

From International Journal of Gynaecology and Obstetrics.

The study set out to compare the efficacy of vaginal versus sublingual misoprostol for second-trimester pregnancy termination, and to evaluate the effect on the blood flow of the uterine and umbilical arteries.

Forty-nine patients were randomised to receive either 200 microg of vaginal misoprostol every 6 hours or 200 microg of misoprostol sublingually every 6 hours. Doppler velocimetry studies were assessed immediately before and 60 minutes after the administration of the first dose. Standard descriptive calculations, Mann-Whitney U, Wilcoxon, and chi(2) tests were performed.

The mean interval between induction and onset of active labour, induction and delivery, and the duration of oxytocin administration were significantly shorter in the sublingual misoprostol group. Both routes of administration increased the Doppler indices for the uterine arteries; however, misoprostol via the sublingual route did not affect the umbilical arteries.

The authors concluded that sublingual administration of misoprostol for second-trimester medical abortion results in a higher success rate and does not affect umbilical blood flow.

Obstetrics Department, Dr Lutfi Kirdar Kartal Education and Research Hospital, Kartal, Istanbul, Turkey. Email:

Vaginal versus sublingual misoprostol for second-trimester pregnancy termination and effect on Doppler measurements. Karsidag AY, Buyukbayrak EE, Kars B, Dansuk R, Unal O, Turan MC. International Journal of Gynaecology and Obstetrics. 2009 Sep;106(3):250-3. Epub 2009 May 9.

Commentary: Population, the environment, and a woman’s right to choose

Fears that a growing world population will worsen the problems caused by climate change have led some to propose voluntary strategies of ‘population reduction’. How should advocates of reproductive choice respond? By Jennie Bristow, Editor, Abortion Review.

Fears that a growing world population will worsen the problems caused by climate change have led some to propose voluntary strategies of ‘population reduction’. How should advocates of reproductive choice respond?

Progressive developments in women’s equality have crucially involved access to safe, legal and effective contraception and abortion. However, history is also populated with examples of circumstances in which contraception, abortion and sterilisation have been imposed upon women, in situations where the authorities – not the woman – decide who should have how many children.

There is now great sensitivity surrounding explicit population control programmes that have been used by governments in the developed world, and imposed on countries in the developing world. Today there is little sympathy within the West for continuing population control programmes such as China’s One-Child Policy, which is being relaxed in some districts. However, it would be naïve to assume from this that birth control today is always promoted positively, with the only considerations being women’s rights and bodily autonomy. Old arguments about why women’s personal reproductive decisions should be made to fit with broader social objectives can be recycled in new forms, and this requires continued vigilance from those working to promote the cause of genuine reproductive choice.

These issues form the backdrop to a debate that has come to the fore in recent years, to do with the impact of continued world population growth upon the natural environment. The issue, starkly put, is framed like this: Climate change is taking place as a consequence of human activity. The more human activity there is, the more climate change will accelerate, posing big problems both for global human society, and for the rest of life on Earth. Recognising this problem means working to reduce the ‘carbon footprint’ that people leave upon the planet. One way of doing this is seen to be to reduce individuals’ consumption of natural resources.

The question of the actual impact upon climate change that can be made by the modification of individuals’ lifestyles continues to be hotly debated. But even if one assumes that reducing humanity’s carbon footprint through changes to individual behaviour should be a key goal, is it acceptable to point to population reduction as a means to this end? Or does that cross the line between promoting birth control as something to be freely used by women, and seeing birth control as something that should be done to women by society, in order to meet instrumental ends?

Who’s arguing what?

In the UK, the debate about the rights and wrongs of population reduction as a strategy to limit the impact of climate change has taken a headline-friendly form through the work of the Optimum Population Trust (OPT). The OPT wants couples to sign up to its online pledge that they will limit their families to two children, for the sake of the environment. It bases its arguments on complex mathematical calculations about how many fewer emissions could be produced if everybody in the world agreed to ‘stop at two’. (1)

The high profile of some of OPT’s patrons – who include Jonathon Porritt, chair of the government’s Sustainable Development Commission, and the famous nature broadcaster David Attenborough – has added to the OPT’s status and the amount of interest its ideas have attracted from the mainstream media. (2) But the Optimum Population Trust is not the only voice calling for population reduction. On both sides of the Atlantic, it is increasingly common to read commentary, often from those who would consider themselves to be on the liberal left or part of the progressive family planning movement, that explicitly or tacitly accepts that the most effective strategy to reduce humanity’s carbon footprint lies in discouraging people from having children. In a revealing, though tongue-in-cheek, online poll for the Guardian newspaper asking whether the UK’s recent ‘baby boom’ was a good thing, only a quarter of respondents chose the answer ‘Yes - we need more young ‘uns to pay for our pensions’, while 75 percent agreed with the statement ‘No - the planet can’t sustain more mouths to feed’. (3)

It should be acknowledged that fears about ‘overpopulation’ are not new; and nor is it new that such fears can be shared and promoted by those who consider themselves to be on the left of the political spectrum. Since Thomas Malthus’ seminal 1798 ‘Essay on the Principle of Population’ concerns about natural, social or economic limits have often taken the form of a discussion about demography. (4) Creating the conditions for smaller family sizes has for decades been viewed by some as a reasonable goal in relation to addressing the problem of poverty in the developing world. In relation to the UK, discouraging young people or those on low incomes from having children, or from having more children, is often argued to be as a pragmatically sensible measure in a social situation where resources are tight.

There are political and philosophical discussions to be had about whether it is accurate or right to view more people as the cause of social and economic problems, or fewer people as a solution. But again, if one accepts at face value the claim that overpopulation is a problem, one still has to answer the question of whether it is acceptable to try to steer women’s reproductive decision-making in a particular direction. If a woman feels under pressure to decide the size of her family forbroader reasons than her own personal circumstances, whose decision is it really?

Coercion and the contours of persuasion

Organisations such as the Optimum Population Trust nowhere suggest that their campaign encouraging people to ‘Stop At Two’ is anything but voluntary. Even the more extreme Voluntary Human Extinction Movement (5) stresses that it has no intention of preventing women from ‘breeding’ if they don’t want to: it merely hopes that they will decide not to. But in a recent debate about this question, Adrian Stott, a trustee of the OPT, suggested that society should provide incentives to women not to have children. (6) When direct incentives are offered to push fertility trends in a particular direction, personal decision-making becomes subject to wider considerations, and is therefore compromised. Serious questions have to be asked about how genuine the commitment to free choice is among those who ultimately would like women to choose not to have children, or more than a certain number of children.

This danger is highlighted by the US women’s health activist Betsy Hartmann, debating on Alternet against a proponent of the view that population growth will damage the environment. (7) ‘Raising alarms about overpopulation distracts us from the real environmental tasks at hand,’ writes Hartmann. ‘It also undermines the provision of good quality, voluntary family planning services, instead legitimising topdown punitive policies that hurt women.’ She concludes:

‘Women’s health activists, in the US and around the world, have fought long and hard for the right to safe, voluntary birth control and abortion services. Pitted against them are not only religious fundamentalists who would deny them access to contraception, but those who are prepared to sacrifice reproductive rights, and human rights, on the altar of population control … The war on population always has been, and will continue to be, a war on women’s bodies.’

If it is accepted in principle that it is right for women to make reproductive decisions based on social ends, rather than their own personal choices and circumstances, then it becomes relatively easy
for state authorities to introduce policies that validate one choice over another. This poses a clear threat to women’s autonomy and the meaning of ‘choice’.

Even if such policies are not explicitly formulated, it is problematic to assume that ‘responsible decision-making’ means women basing their decisions, not on whether they want a child and are capable of raising it, but on a generalised expectation of how many children it is right to have on a global or national level. As Hartmann suggests, pro-choice advocates have fought their arguments on the basis that the woman should be absolutely at the centre of reproductive decision-making. It is a woman who must bear a child, and in our society it is usually she who will have the practical, emotional and financial responsibility for raising that child. To attempt to displace the woman from this decision by encouraging her to regulate her fertility in line with the abstract demands of ‘the environment’ implicitly pushes the woman to a more marginal, negotiable and ultimately vulnerable position in the decision-making process.

The problem with the ‘pro-life’ perspective

Understanding the problematic character of the arguments put forward by organisations such as the Optimum Population Trust and other supporters of population reduction does not mean that these organisations should not be allowed to air their opinions freely, or that to debate population and the environment is dangerous in itself. Debate provides an opportunity to clarify the meaning and consequences of these campaigns. It also, importantly, puts the onus on advocates of choice to engage with this debate on terms that we can fully support.

One unfortunate feature of the debate about population and the environment to date has been that, with a few exceptions, the most coherent and high-profile critiques of the goal of population reduction have come from those who oppose contraception and abortion per se. It is easy to understand why those who object to individual women controlling their fertility because they believe in the sanctity of life from the moment of conception will also balk at the idea that women’s fertility should be controlled for the sake of the natural environment.

But while many such critics of population reduction correctly identify an element of misanthropy, they are rarely challenged about the degree of misanthropy within glib pro-life arguments, which equate ‘human life’ in its basic, biological, potential form with the life of an adult woman, and demand that biology should be what determines the life of this woman from conception onwards.

To allow the anti-abortion perspective to dominate the opposition to population reduction arguments risks making the pro-choice movement appear one-sided in its commitment to the choice not to have children. It will also fail to convince those who do not believe that an embryo or fetus has the same moral status as a baby, and do not believe that all conceptions should result in live births just because they have occurred, but who are nonetheless troubled by the suggestion that it is a positive social goal to encourage women not to have the number of children that they want. To breed or not to breed: the only question here should be whose choice it is, and the answer has to lie with the woman who will bear and raise her child.

This article appears in the Autumn 2009 print edition of Abortion Review. /b>

Clinical Update: Reducing serious infection following early medical abortion

By Professor James Trussell, Director of the Office of Population Research, Princeton University.

This Q&A is based on the paper ‘Rates of serious infection after changes in regimens for medical abortion’, by Fjerstad M, Trussell J, Sivin I, Lichtenberg ES, Cullins V. New England Journal of Medicine 2009 Jul 9;361(2):145-51.

Q) What was the rate of serious infection following early medical abortion in Planned Parenthood (PP) health centres between 2001 and 2006?

From 2001 through March 2006, PP health centres provided 219,724 medical abortions to 63 days’ gestation by a regimen of 200 mg oral mifepristone followed 24-48 hours later by 800 μg of vaginal misoprostol, self-administered at home. During the period 2001-Q1 2004, the rate of infection requiring inpatient or outpatient treatment was 23/100,000 medical abortions. Concerns about incomplete reporting of medical abortion led to two changes: 1) PPFA (Planned Parenthood Federation of America) Medical Standard and Guidelines were changed in 2004 to require that all serious adverse events be reported centrally to one person; 2) Planned Parenthood health centres are audited on-site for internal accreditation by PPFA. Since 2005, the accreditation process has included auditing to verify that mifepristone adverse events are submitted as required.

The rate of serious infection at PP health centres during the period 2005-Q1 2006 was 89/100,000, nearly four times that expected from earlier experience at PP. And by late 2005, four women in the US and one in Canada had died from a rare bacterial infection with Clostridium sordellii following medical abortion.

Q) What is a ‘serious’ infection?

We defined serious infections as cases where the patient has fever accompanied by pelvic pain and is treated with IV antibiotics either in an emergency department or in-patient unit, or cases where sepsis or death caused by infection is documented.

Q) What measures were put in place to try to reduce the serious infection rate?

Two changes, neither evidence-based, were made. First, the route of administration of misoprostol was changed from vaginal to buccal (200 mg mifepristone followed 24-48 hours later by 800 μg of buccal misoprostol, 400 μg in each cheek for 20 min). Second, routine antiseptics were replaced by one of two new infection control measures:

- EITHER universal testing for Chlamydia (and gonorrhoea where appropriate (treatment consisting of doxycycline orally 100 mg BID x 7 days for Chlamydia, and for gonorrhoea, ceftriaxone 125 mg IM in a single dose);
- OR routine antibiotic coverage (doxycycline orally 100mg BID for 7 days, starting the same day as mifepristone administration).

Q) What was the outcome of these changes?

The rates of serious infection significantly declined in both groups, by 61% in the screen-and-treat group and 93% in the routine antibiotic group. Because the decline in the routine antibiotic group was significantly greater than the decline in the screen-and-treat group, in July 2007, PPFA required all health centres to provide antibiotics to all women having medical abortions.

Q) What can researchers and practitioners conclude from this?

The joint change from:

- Vaginal to buccal administration of misoprostol and
- Standard antiseptic measures to routine antibiotic coverage

reduced the rate of serious infection by 93%, from 92.8 to 6.9 per 100,000. Unfortunately, it is not possible to know what share of the overall decline was associated with each change individually since both were made at the same time. However, because there was a further significant decline in the serious infection rate when the screen-and-treat group subsequently changed to routine antibiotic coverage, we know that the change to routine antibiotic coverage alone must account for some of the decline.

Q) How does the situation in the USA differ from that in the UK - both in terms of infection rates and clinical practice?

The rate of serious infection following medical abortion in the UK is not known. Buccal administration of misoprostol is rare. However, many, if not most, but certainly not all providers of medical abortion in the UK follow the 2004 RCOG guidelines that mandate routine antibiotic coverage (though not with doxycycline).

Q) Are there any lessons to be learned in the UK from the US experience?

All we can report is what happened when we made changes. Questions remain about whether routine antibiotic coverage is cost effective in either the US or the UK.

***

EARLY MEDICAL ABORTION AT BPAS
By Patricia Lohr, Medical Director, BPAS

At BPAS, EMA is undertaken by administration of 200 mg oral mifepristone followed 6-72 hours later by 800 mcg misoprostol inserted vaginally in the clinic, either by the client or a nurse depending on the woman’s preference. We use vaginal misoprostol because it offers the greatest flexibility in the interval between medications, lowest rate of side effects, and high effectiveness. We do have the option of using regimens with oral or buccal misoprostol for women who cannot tolerate vaginal administration, but they are uncommonly used.

All women undergoing EMA at BPAS receive prophylactic treatment for Chlamydia. Our standard regimen is doxcycline 100 mg orally twice a day for 7 days (the same regimen used in the New England Journal of Medicine paper, reported on above) although we have some contracts that specify use of a single oral dose of azithromycin 1g.

For more information about the provision of EMA at BPAS, see the publication Early Medical Abortion: A Guide for Practitioners, available to download for free here.

USA: Effect of mifepristone on abortion access in the United States

From Obstetrics and Gynecology. 

The study set out to examine the pattern of mifepristone uptake in the United States and whether the introduction of this drug has facilitated access to abortion services. Using data from a national census of abortion providers and from the U.S. distributor of mifepristone, researchers assessed the number and proportion of abortions performed using mifepristone, the distribution of mifepristone providers by provider type and medical specialty, and the geographic distribution of mifepristone and surgical providers.

Results found that the number of mifepristone providers increased from 208 in the last 2 months of 2000 to 700 in 2001, the first full year of availability, and to 902 in 2007. Some 158,000 mifepristone abortions were performed in 2007, representing an estimated 14% of all abortions and 21% of eligible early abortions. Physicians represented 51% of mifepristone providers but accounted for just 11% of abortions; most were obstetrician-gynecologists.

The proportion of abortions in each state performed using mifepristone ranged from 0% to 80%. Most mifepristone abortions were performed at or near facilities that also provided surgical abortion. Only five mifepristone-only providers of 10 or more abortions were located farther than 50 miles from any surgical provider of 400 or more abortions.

The authors concluded that mifepristone has become an integral part of abortion provision in the United States and likely has contributed to a trend toward very early abortions. However, expectations that approval of mifepristone would result in a wider range of providers offering abortion have not yet been met, and mifepristone has not brought a major improvement in the geographic availability of abortion.

Guttmacher Institute, 125 Maiden Lane, New York, NY 10038, USA. Email

Effect of mifepristone on abortion access in the United States. Finer LB, Wei J. Obstetrics and Gynecology. 2009 Sep;114(3):623-30.

Canada: Low birth weight, preterm birth and abortion

A review published in the BJOG has suggested that women with a history of termination of pregnancy may have an increased risk of low birth weight and preterm birth in subsequent pregnancies. The study found that the risk increased as the number of terminations increased.

In this meta-analysis, researchers from the Knowledge Synthesis Group of Determinants of preterm/LBW births in Toronto, Canada reviewed 37 studies of low to moderate risk of bias. Data from 1965 to 2001 was included in the studies. The studies took place in a range of international locations.

The results found that a history of termination of pregnancy (TOP) was associated with an increased risk of low birth weight (OR 1.35) and preterm birth (OR 1.36), but not small for gestational age. A history of more than one TOP was associated with an increased risk of low birth weight (OR 1.72) and preterm birth (OR 1.93).

The authors stress that further studies are needed to assess the impact of newer techniques, and to identify the safest method of pregnancy termination in the first and second trimester. Recent changes such as access to early medical abortion, and the use of medications such as misoprostol prior to surgical intervention, may minimise trauma to the cervix. Outcomes in subsequent pregnancies thus need to be assessed and compared to those observed in older studies.

Lead author, Dr. Prakesh Shah, from the Department of Pediatrics at Mount Sinai Hospital in Toronto, said: ‘several biomedical, social, environmental, lifestyle-related, genetic and other factors contribute to preterm and low birth weight births, and this needs to be kept in mind when interpreting our results. We caution against causal interpretation of these results as the confounding effects of socioeconomic factors, which are important, were considered in very few studies.

‘Any discussion regarding the downsides of TOP is incomplete without discussing the downside of unwanted pregnancies, as they are also at risk of adverse outcomes.’

Prof. Philip Steer, BJOG editor-in-chief, said: ‘This study highlights the need to assess and improve techniques in order to make termination of pregnancy safer for women.

‘There is no question that TOP remains an essential part of women’s healthcare. However, it is important to evaluate the risks and benefits of different techniques in order to ensure safe procedures and healthy future pregnancies for women.’

Patricia Lohr, Medical Director of BPAS, said: ‘As the study’s authors point out, a causal relationship between abortion and adverse pregnancy outcomes cannot be determined from this paper. There are multiple confounding factors affecting low birth weight and premature births that were not examined in many of the previously published studies which were assessed in this paper. 

‘We know from other research that adverse pregnancy outcomes often involve other risk factors to health: being poor, unemployed, or the effects of alcohol use and smoking. These risk factors can be difficult to separate from a woman’s previous history of abortion or miscarriage. 

‘It’s a central principle for BPAS that women are informed of relevant health information if they are considering an abortion. On the basis of the evidence to date however, it would inappropriate for doctors advise women that there has been anything more than an association made between abortion and adverse pregnancy outcomes. We already do this in our patient literature. This study sheds no light on the contributory effect of one abortion procedure over another.’

Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses. Shah P, Zao J on behalf of Knowledge Synthesis Group of Determinants of Preterm/LBW Births. BJOG 2009; 116:1425–1442. DOI: 10.1111/j.1471-0528.2009.02278.x.

BJOG release: Termination of pregnancy associated with increased risk of low birth weight and preterm birth. Royal College of Obstetricians and Gynaecologists, 16 September 2009

BPAS comment on media discussion of abortion, low birth weight and prematurity. BPAS, 15 September 2009

Spain: Plans for abortion on demand in first trimester

The Socialist government has formally unveiled proposals to reform the country’s abortion law.

Under the proposal approved by the cabinet, abortion would be made available on demand for the first time. Girls as young as 16 would be allowed to terminate a pregnancy without parental consent.

Ministers say it is about ‘rights and respect’ for women, BBC News Online reports. The conservative opposition says young people may see abortion as a form of contraception.

Spain’s current law allows a pregnancy to be terminated in three circumstances - in the aftermath of a rape, when a fetus shows genetic defects, and when the health of the pregnant woman is at risk. The government’s proposal is that abortion should be made available on demand during the first 14 weeks of a pregnancy.

The opposition has vowed to challenge the bill, arguing that it does not have broad support in Spanish society. The Catholic Church also opposes any change in the law, and has called on its followers to join an anti-abortion rally in Madrid next month.

The existing abortion law was passed in 1985 - a decade after the death of General Franco. On paper, it appears strict. But in practice, many Spanish women have been able to secure abortions by arguing that pregnancy was endangering their mental health.

Spain unveils abortion law change. BBC News Online, 26 September 2009

Also read:

Spain: Progress reported in abortion law reform Abortion Review 22 September 2009

Spain: Legal reform on the cards Abortion Review 15 May 2009

Spain: Church and state clash over abortion law reform Abortion Review 17 March 2009

Motherhood in the 21st Century

Two recent conferences raised important questions about the way that medical discourse is framing concerns about the ‘optimal’ time and circumstances in which women should reproduce. By Jennie Bristow.

An inter-disciplinary conference held at University College London on 18 September 2009 brought together scientists, clinicians, ethicists, anthropologists and several notable names in the field of fertility treatment to address the topic of ‘Motherhood in the 21st Century’. (1) Speakers addressed questions such as: What is the relationship between maternal age and biological fertility? What are the clinical and ethical issues in treating women approaching, or beyond, the age of menopause? At what age should a woman be considered ‘too old’ to be given fertility treatment to enable her to have a child? 

For those working in the field of reproductive choice, these recent debates surrounding the use, and potential abuse, of fertility treatment raise a host of familiar issues. Moral judgements about the use of technologies such as IVF that interfere with a woman’s ‘natural’ fertility, often-politicised discussions about the kind of women who should and should not be encouraged to have children, and the relationship between clinical developments and legal regulations all have their parallels in discussions around contraception and abortion.

However, while the idea that women should not be forced to bear unwanted children is well accepted in the UK, the question of whether women should have a ‘right’ to access fertility treatment is a newer, and more contentious, area of debate. Speakers at the ‘Motherhood in the 21st Century’ conference sought to untangle the risks and opportunities provided by recent developments in fertility treatment, and to address the clinical and ethical dimensions that arise from the trend towards later motherhood, which has arisen in part from women’s decisions not to have children earlier in life.

Opening the proceedings, Lord Robert Winston argued that it was ‘regrettable’ to see the Royal College of Obstetricians and Gynaecologists (RCOG) wringing its hands over the trend for women to have babies later in life. (2) He argued that it should not be the role of the medical profession to worry about when women have their children. The focus in debates about ‘older mothers’ on women over the age of 55 is ‘inappropriate’, as these represent an extremely small number of the women giving birth.

Where there is a problem, Lord Winston explained, is in relation to women in their forties and their early fifties; and here, many of the problems were to do with the way the NHS and the private sector is ‘exploiting women in different ways’. He gave as examples of this exploitation the ‘scandal’ of expensive IVF cycles, and the issue of egg sharing, whereby women seeking fertility treatment are given a reduction in price in exchange for sharing the eggs they produce under treatment with another patient. This situation has become exacerbated with the legal changes surrounding donor anonymity, which has given rise to a potential scenario in which a woman unsuccessfully undergoes treatment using her own eggs, but is contacted 18 years hence by a child born to another woman using the first woman’s eggs.

Professor Sammy Lee, Chief Scientist of the Wellington Hospital IVF programme and convenor of the ‘Motherhood in the 21st Century’ conference, spoke briefly about why he had organised the event. The public views the idea of a 70-year-old woman carrying and delivering a baby as shocking, he explained – ‘but they do not know why. Faced with such widespread prejudice, this topic needs to be aired in public and the real issues determined and then debated’. Biological age should not be the only considerations taken into account when looking at mothers who have children later in life, suggested Lee: ‘indeed, the special love and drive such mothers have makes the endurance of motherhood a pleasure rather than a burden’.

In an interesting scientific presentation, Professor John Carroll, Associate Dean of UCL Division of Biosciences, described why women aged 35-45 experience a ‘precipitous decline in fertility’. Humans generate a limited and finite number of eggs, and eggs from older mothers are ‘prone to serious chromosomal errors that result in the generation of embryos that have limited developmental potential’. Further research into how eggs are made, stored and released may, suggested Carroll, provide new opportunities to treating sub-fertility in the future.

Peter Brinsden, MB FROG, Consultant Medical Director at the Bourn Hall, addressed the issues involved in treating older mothers. Noting that ‘the ready availability and wide choice of reliable contraception has been a major revolution in the lives of women in the last 40 years’, Brinsden argued that this has led to an increasing tendency for women to delay starting their families, with the result that ‘many women are now attending fertility clinics in their forties, and even fifties, having found that they cannot easily become pregnant, and [expecting] that IVF and related advanced fertility treatments will resolve their problem’.

Because of the relative lack of success of IVF to older women, Brinsden pressed the point that ‘women of all ages’ should be ‘fully informed of the consequences of delaying motherhood’. An audience member challenged his assumption that women were consciously deciding to delay motherhood because they had invested false hopes in the effectiveness of fertility treatment, and the idea that women should be pressed to worry about the optimal age at which they might have a child was tackled in further presentations.

Professor Dr N. Pandiyan, Chief Consultant in Andrology and Reproductive Medicine at Chettinad University, India, argued that ‘sex and reproduction are fundamental rights of every individual’, and that ‘where society cannot give the necessary help due to financial / resource / religious constraints, it should at least stay away from individuals achieving their desired goals by rightful means’. The decision about when to have a child, stressed Pandiyan, is a personal one ‘to be made by the couple in consultation with the doctor and the fertility centre, and not by any of us.’

Professor Anna Smajdor of the University of East Anglia, drew out the problematic of the ‘implicit ethical assumption’ that ‘women should reproduce at the optimal time’ – which in terms of medical risk is seen as between the ages of 20 and 35. If the discourse around reproduction is dominated by a preoccupation with medical risk, argued Smajdor, the consequence is to argue that women should not reproduce at all, as pregnancy and childbirth are risky for women at any age. If reproduction is recategorised as a necessary risk, but the narrow focus on medical risk is retained, this can lead to an ‘implicit pronatalism’ that views women’s responsibilities primarily in relation to the health of their potential pregnancies.

The problem of a new form of pronatalism, framed by a narrow preoccupation with medical risk, was addressed at a different conference organised by the academic Parenting Culture Studies network, in Birmingham on 16-17 September. (3) One session examined the phenomenon of ‘extending pregnancy backwards’ – a process by which the behaviours and anxieties associated with pregnancy are promoted to all women, on the grounds that they may become pregnant someday.

Rebecca Kukla, author of Mass Hysteria: Medicine, Culture and Mothers’ Bodies, described the growing trend towards ‘preconception care’. This policy idea promotes the notion that the way to ensure the birth of healthy babies is to ensure that all women of childbearing years are treated by doctors less as individual women than as potential mothers. This makes them subject to increasing lifestyle modification advice and lends itself to a situation where women may be given medical treatment determined on the basis of what might have the least adverse outcome for a potential fetus, rather than what will work best for the woman herself, right now. As Kukla put it, ‘Women’s healthcare is increasingly co-opted by reproductive management – whether or not a child is involved.’

The practical consequences of treating all women as mothers-in-waiting for the healthcare they are given are disturbing. But the broader cultural effect of such ‘preconception planning’ might also give us pause. One great achievement of the movement for reproductive choice has been to move away from assumptions that women matter, first, as mothers or potential mothers. A shift towards viewing, and treating, women in terms of their ability to become the optimal pregnant person could be seen as a step backwards for assumptions about women’s autonomy, both in terms of their treatment by health services and the wider validation of women’s lives. 

Jennie Bristow is editor of Abortion Review.

(1) ‘Motherhood in the 21st Century’ conference
(2) Concerns over older mother trend. BBC News Online, 12 June 2009
(3) Parenting Culture Studies

Australia: Infertility, medical advice and treatment with fertility hormones and/or IVF

From the Australian and New Zealand Journal of Public Health.

The study’s objective was to identify the factors associated with infertility, seeking advice and treatment with fertility hormones and/or in vitro fertilisation (IVF) among a general population of women.

Participants in the Australian Longitudinal Study on Women’s Health aged 28-33 years in 2006 had completed up to four mailed surveys over 10 years (n=9,145). Parsimonious multivariate logistic regression was used to identify the socio-demographic, biological (including reproductive histories), and behavioural factors associated with infertility, advice and hormonal/IVF treatment.

The results found that for women who had tried to conceive or had been pregnant (n=5,936), 17% reported infertility. Among women with infertility (n=1031), 72% (n=728) sought advice but only 50% (n=356) used hormonal/IVF treatment. Women had higher odds of infertility when: they had never been pregnant (OR=7.2, 95% CI 5.6-9.1) or had a history of miscarriage (OR range=1.5-4.0) than those who had given birth (and never had a miscarriage or termination).

The authors concluded that only one-third of women with infertility used hormonal and/or IVF treatment. Women with PCOS or endometriosis were the most proactive in having sought advice and used hormonal/IVF treatment. They argued that raised awareness of age-related declining fertility is important for partnered women aged approximately 30 years to encourage pregnancy during their prime reproductive years and reduce the risk of infertility.

School of Population Health, The University of Queensland.

Infertility, medical advice and treatment with fertility hormones and/or in vitro fertilisation: a population perspective from the Australian Longitudinal Study on Women’s Health. Herbert DL, Lucke JC, Dobson AJ. Australian and New Zealand Journal of Public Health. 2009 Aug;33(4):358-64.

Poland: Ruling against Catholic magazine

A Polish court has awarded $11,000 (7,400 euros) in damages to a woman likened to a child killer for wanting an abortion.

The article, in the Catholic magazine Gosc Niedzielny, also compared abortion to the experiments of Nazi war criminals at Auschwitz, BBC News Online reports.

Alicja Tysiac had been warned by doctors when she became pregnant that she could go blind if she had her baby. But she was denied an abortion - illegal in most cases in Poland - and her eyesight subsequently deteriorated.

The court in Katowice, southern Poland, ruled that the magazine had drawn clear parallels between Ms Tysiac’s desire to have an abortion and the actions of Nazi war criminals. The judge said it had shown ‘contempt, hostility and malice’ towards the 38-year-old woman. He said Catholics have the right to express their disapproval of abortion and even call it murder, but they did not have the right to vilify individuals.

Ms Tysiac’s sight problems grew worse following the births of each of her three children. Acting on medical advice, she decided to have an abortion when she became pregnant for a third time eight years ago but her gynaecologist refused to perform the procedure.

Poland has strict abortion regulations but they are allowed when the health of the mother or embryo is threatened. Two years ago, the European Court of Human Rights ordered Poland to pay Ms Tysiac 25,000 euros ($36,000) in compensation. The Catholic magazine wrote that she had been compensated for wanting to kill her child.

The magazine’s editor-in-chief, Father Marek Gancarczyk, said the ruling was unfair and denied comparing Ms Tysiac to Nazi criminals. His lawyers said they would use the principle of freedom of speech to appeal against the court’s verdict.

Award for Poland abortion woman. BBC News Online, 23 September 2009

Spain: Progress reported in abortion law reform

The Equality Minister says she hopes to take the government’s planned reform of the Abortion Law to the next Cabinet meeting, after the Consejo de Estado accepted in September that the reforms are constitutional. 

They recommended, however, that parents should be involved if an underage girl wants to terminate her pregnancy unless there are well-founded reasons that would cause a serious conflict at home if her parents were informed.

The government proposes to allow unconditional abortion at 14 weeks from the age of 16 without parental consent, in a major overhaul of the current legislation which has been in place since 1988. The law currently states that abortion is only permitted in the case of rape, if the fetus is seriously deformed, or if there is a risk to the mother’s physical or mental health.

Minister Bibiana Aído said that, while she sees the draft bill as the ‘best of all the possibles’, greater consensus is needed if it is to be approved by parliament.

A protest march against the reforms has been announced in Madrid on 17 October, and the former Partido Popular Minister for the Interior, Jaime Mayor Oreja, has told Europa Press this weekend that he will be taking part.

Spain’s Equality Minister to take abortion reform to next Cabinet meeting. TypicallySpanish.com, 20 September 2009

Canada: Bacterial sacroiliitis and gluteal abscess after D&C for incomplete abortion

This study reports on the case of a young woman whi presented to the emergency department with rapidly progressive left-sided lower back pain, general malaise, and chills evolving over the previous 48-hours after dilation and curettage for incomplete abortion. From Obstetrics and Gynecology.

Pyogenic infection with Streptococcus agalactiae is a potentially life-threatening disease associated with significant morbidity and mortality. This type of infection has seldom been reported as a complication of dilation and curettage after an incomplete abortion.

This study reports on the case of a young woman whi presented to the emergency department with rapidly progressive left-sided lower back pain, general malaise, and chills evolving over the previous 48-hours after dilation and curettage for incomplete abortion. Streptococcus agalactiae was isolated in the blood. The patient developed pelvic osteomyelitis despite aggressive medical therapy and required prolonged treatment before significant clinical improvement was noted.

The author concluded that, although very rare, serious pyogenic complications of dilation and curettage after incomplete abortion do occur and may present a diagnostic challenge.

Division of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada.

Bacterial sacroiliitis and gluteal abscess after dilation and curettage for incomplete abortion. Yansouni CP, Ponette V, Rouleau D. Obstetrics and Gynecology. 2009 Aug;114(2 Pt 2):440-3. 

fpa launches campaign to ‘enjoy sex responsibly’

Alcohol is commonly seen as a factor in not using a condom with a new partner, regretting sexual activity and having sex with someone who would not normally be found attractive, says the UK sexual health charity.

The charity’s claims are based on new research published by fpa during Sexual Health Week 2009. The charity wants to encourage greater public recognition that alcohol can and does influence sexual decision making, and is distributing posters and leaflets across the UK to encourage people to ‘Enjoy sex responsibly’.

Of the 1,002 people aged 18–30 who had past experience of both alcohol and sex, surveyed online by Ipsos MORI on behalf of fpa, 37% said they had ‘had sex with a new partner without using a condom’. Of this group, 40% said that alcohol was a factor (either a great deal or a fair amount) in what happened.

Of the 38% of all respondents who said ‘I have taken part in sexual activity with someone and then regretted it later’, 70% of these said alcohol was a factor (either a great deal or a fair amount) in what happened. Over a quarter of all respondents (28%) had sex with someone they normally wouldn’t find attractive (fancy), with 73% of them giving alcohol as a factor.

Julie Bentley Chief Executive of fpa, said of the findings:  ‘People don’t go out to take risks, they go out to have a good time. People may start with the best intentions, but drinking alcohol reduces the chances of using a condom with someone new and impairs sexual decision making. fpa isn’t here to tell people how much they should or shouldn’t drink. Our point is, that you’re more likely to take chances with your sexual health if you’ve drunk alcohol.’

Among the group who had not used a condom with a new partner and said they thought alcohol was a factor in the decision (15% of all respondents in total), one in eight (13%) reported that on at least one occasion they or the person they had sex with became pregnant (unplanned). Another 7% of them said that they had contracted a sexually transmitted infection (STI).

Bentley commented: ‘The fact that some people in our research experienced an unplanned pregnancy or an STI as a result of sex under the influence of alcohol is extremely worrying. However, it’s likely there are more people who simply won’t ever know if the sex resulted in a pregnancy, STI or not as they never see that person again.’

The research revealed a difference between an individual’s perceptions of their own behaviour when drinking compared to that of others. Eighty-three per cent agreed with the statement ‘In general people are less likely to use a condom or other contraception when they have sex if they have been drinking alcohol’. However, only 40% agreed that ‘I am less likely to use a condom or other contraception when I have sex if I have been drinking alcohol’. Nine per cent of respondents said that they have been unable to remember whether or not they had sex or exactly what type of sexual activity took place.

Unplanned pregnancy and sexually transmitted infections...a sobering thought? fpa press release, 17 September 2009

Australia: Teenager charged with procuring own abortion

The Sunday Mail (Queensland) reports on the teenager facing the state’s first abortion trial in nearly 25 years. 

Tegan Leach, 19, is staying in a secret location in north Queensland after the house where she previously lived was firebombed shortly after she first went to court on charges she allegedly procured her own abortion by using the controversial drug RU486 (mifepristone), Gavin King reports.

She has since lost her job, while the stress of the committal procedure – and the ferocity of some public reaction to the case – has made her feel a prisoner in her own home. King reports that she is distraught and confused, but determined to beat the charges which could put her in jail for up to seven years.

The case has reignited the abortion issue in the state to a level not seen since 1986 when the late Dr Peter Bayliss and anaesthetist Dawn Cullen went to court and beat charges arising from the operation of an abortion clinic in Greenslopes in Brisbane’s south.

Standing by Ms Leach’s side is her 21-year-old boyfriend Sergie Brennan, who faces charges that he allegedly supplied drugs to procure an abortion. If convicted he could face a maximum penalty of three years’ jail. Ms Leach’s solicitor, Bernie Carman, told the Sunday Mail that the turmoil had strengthened the bond between them.

Although Mr Carman described the couple as ‘resilient’, their ordeal is far from over. They will have to wait up to nine months for their trials to begin. It is certain to be an anxious time, for many reasons, including the intense interest in the case from pro-life and pro-choice campaigners across the nation.

Doctors across Queensland are continuing their ban on most abortions until the government gives them a guarantee they would not be charged with a crime. Obstetrician Caroline de Costa told the Sunday Mail that up to 30 women had travelled interstate for abortions over the past three weeks. Doctors say more than 14,000 abortions are performed in Queensland each year.

Teen’s ordeal over abortion trial. Sunday Mail, 13 September 2009

USA: Intimate partner violence and issues of fertility control

The purpose of this study was to examine the association between intimate partner violence (IPV), abortion, parity, and contraception use. From American Journal of Obstetrics and Gynecology. 

The authors recruited 1463 women for this written questionnaire study of IPV. Patient demographics, contraceptive history, and reproductive history were obtained in the waiting room from patients presenting for gynecologic care.

Seventy percent of those eligible participated. Twenty-one percent reported a history of IPV. Partner unwillingness to use birth control, partner desirous of conception, partner creating difficulty for subject’s use of birth control, and subjects expressing inability to afford contraception were all positively associated with report of IPV. Each additional pregnancy was associated with 10% greater odds of IPV (95% confidence interval, 1.03-1.17).

The authors concluded that contraception is more difficult to navigate for women experiencing IPV. Providers should consider prescribing contraceptive methods for IPV victims that are not partner dependent.

Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.

Power over parity: intimate partner violence and issues of fertility control. Gee RE, Mitra N, Wan F, Chavkin DE, Long JA. American Journal of Obstetrics and Gynecology. 2009 Aug;201(2):148.e1-7. Epub 2009 Jun 28. 

USA: The role of nursing in the management of unintended pregnancy

From The Nursing Clinics of North America.

This article explores the role of nurses in the prevention, management, and treatment of unintended pregnancy.

The authors note that all nurses have a responsibility to understand the importance of reproductive health care in the primary care of women and their families, and to be prepared to respond to patients’ needs for the prevention and management of unintended pregnancy. A public health framework provides an opportunity to identify the role of the nurse in primary, secondary, and tertiary prevention strategies that can contribute to the management of unintended pregnancy for the health of women and their families.

Nursing education and the role of nurses in advocacy for reproductive health concerns are also addressed.

Department of Obstetrics/Gynecology and Reproductive Sciences, School of Medicine, University of California San Francisco, San Francisco, CA 94110, USA.

The role of nursing in the management of unintended pregnancy. Levi AJ, Simmonds KE, Taylor D. The Nursing Clinics of North America. 2009 Sep;44(3):301-14. 

The ABC of SRE

Report on the recent conference ‘SRE 2009: International Perspectives on The Approaches, Benefits and Constraints of Sex and Relationships Education’. By Abigail Fitzgibbon, Press and Public Policy Officer, BPAS.

Professionals from a range of backgrounds came together in Birmingham from 7-9 September for a major conference on Sex and Relationships Education (SRE). ‘SRE 2009: International Perspectives on The Approaches, Benefits and Constraints of Sex and Relationships Education’ featured presentations from speakers including Diana Johnson MP, Parliamentary Undersecretary of State for Schools; John Santelli of Columbia University; and many practitioners who spoke about best practice in SRE.

Of particular significance for those concerned with the inclusion of abortion education within SRE was the presentation from Lisa Hallgarten of Education for Choice. Education for Choice is a charity that believes all young people should have access to factual, evidence-based information about abortion and impartial decision-making support, and it works to achieve this practically in schools, with teachers and through advocacy work.

Hallgarten explained that, because the anti-abortion movement has been unsuccessful in gaining public support for its ethics-based opposition to abortion, it now uses a model of misinformation. By spreading myths linking abortion to infertility and breast cancer, anti-abortion campaigners have confused the debate, which is a particular problem when they are invited into schools to present to children and young people.

Anti-abortion organisations are asked into schools for several reasons. Teachers are concerned about ensuring that debate within the classroom is ‘balanced’, which leads to inclusion of anti-abortion organisations in abortion education, even when the discussion is supposedly factual. There may also be ideological opposition to the pro-choice perspective from the school or individuals within it. Hallgarten argued that there is a place for debating the ethics of abortion – however, arguing an ethical opposition to abortion is not the same as arguing that abortion causes infertility. To illustrate this point she used a quote from the TV series The Wire: ‘A lie ain’t a side of the story: it’s just a lie’.

Delegates heard how good practice in abortion education can be achieved by exploring the different opinions and values of students by getting young people to empathise with the pregnancy decision-making process a woman has to go through. This is followed by prompting further discussion, asking questions such as ‘How do different views on abortion impact on women’s lives?’ and ‘How do women reconcile their faith and values with the abortion decision?’.

Hallgarten concluded her presentation with the message that it is possible to have a discussion about abortion in schools, in which those of all views can feel safe and comfortable in expressing those views. That discussion should be evidence-based, include accurate sexual health information about pregnancy prevention, and incorporate some work around empathising and pregnancy decision-making.

The conference closed with a session on faith and SRE, and featured expert speakers discussing how practitioners and policy-makers can approach communities to get them on board with SRE, and how faith can be an asset rather than a barrier to setting up good SRE. Delegates heard from Sara Nasserzadeh, an independent consultant who specialises in working with the Muslim community on SRE. She explained that Muslim parents have a responsibility to look after the physical, emotional and mental health of their children and SRE could be used to help them fulfil this duty. She stressed that working with the community by indentifying key local people would be the best way to develop effective SRE that would be accepted and in keeping with Islamic values.

Following on from this Jon O’Brien, President of Catholics for Choice, discussed the way in which his organisation is interested in Catholicism ‘as it is lived by Catholics, not as it is imagined by its leaders’. It should not be assumed that Catholic parents are opposed to SRE, and policymakers and Parliament should not suppose that bishops always speak to the views of Catholic people.

Hansa Patel-Kanwal, an independent consultant, spoke about her positive experience of carrying out a consultation on SRE, which led to the formulation of a ‘Values Framework’ for SRE that is now being rolled out across all schools in Waltham Forest. Her work brought together parents from all faith groups in the local area to discuss SRE, and found there was much common ground. Parents agreed that relationships should be the focus of SRE and that it should empower and enable children and young people to resist peer pressure and make informed decisions. In conclusion she stated that while sometimes faiths will need to agree to disagree there should always be a basis of mutual respect and we owe it to young people to find innovative ways to deliver SRE. 

Canada: Rates of spontaneous and therapeutic abortions following use of antidepressants in pregnancy

Researchers compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of spontaneous abortion (SA) and therapeutic abortion (TA). From Journal of Obstetrics and Gynaecology Canada. 

The authors note that the use of antidepressants during pregnancy remains a controversial issue, and there is little information on the risk of spontaneous abortions following antidepressant exposure in early pregnancy. They sought to examine whether use of antidepressants increases the rates of spontaneous abortion (SA) and therapeutic abortion (TA) in women exposed in early pregnancy.

In a cohort of women who contacted the Motherisk program during pregnancy, researchers compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of SA and TA.

Among 937 women exposed to antidepressants prior to and during early pregnancy, there were 122 SAs (13.0%) including three ectopic pregnancies, and in the comparison group there were 75 SAs (8.0%) and no ectopic pregnancies. The relative risk was 1.63 (95% CI 1.24-2.14). Three-fold more women reported a TA in the exposed group, 26 (2.4%) compared to 8 (0.7%) in the non-exposed group (RR 3.25; 95% CI 1.48-7.14). A sub-analysis revealed that in both groups, of 338 women with a prior SA, 58 (17.2%) reported having a SA in the current pregnancy, compared with 61/652 (9.4%) with no prior SA (chi square = 12.09, P lt; 0.001). In the antidepressant group, the incidence was 20.7%, and in the non-exposed group, it was 13.3%. Logistic regression confirmed that only antidepressant exposure and prior SA were significantly associated with current SA.

The authors concluded that exposure to antidepressants in the first trimester of pregnancy appears to be associated with a small but statistically significant increased risk of SA and decision to terminate a pregnancy. The risk for SA is further elevated with a history of previous SA. However, any underlying depression must be taken into consideration when evaluating these results.

The Motherisk Program, The Hospital for Sick Children, Toronto, ON.

Rates of spontaneous and therapeutic abortions following use of antidepressants in pregnancy: results from a large prospective database. Einarson A, Choi J, Einarson TR, Koren G. Journal of Obstetrics and Gynaecology Canada. 2009 May;31(5):452-6. 

Australia: Knowledge of and attitudes to EC among university students

This study set out to explore first year Australian university students’ knowledge and attitudes about emergency contraception and their understanding of the risk for pregnancy. From the Australian and New Zealand Journal of Public Health. 

A self-report questionnaire was completed by a convenience sample of 627 first year on-campus students from both health and non-health disciplines.

The results found that knowledge about emergency contraception (EC) was generally poor including misunderstanding that it can only be used the ‘morning after’, as well as where it may be accessed. Its potential use was, however, more highly accepted as a preventative measure after unprotected sexual intercourse than abortion in the event of unplanned pregnancy. Women had better knowledge than men, and on a number of measures there were significant differences between these groups.

The authors concluded that poor knowledge about the timing, accessibility, action and side effects of EC may act as a barrier to its use in the event of unprotected sexual intercourse. Although EC has been available in Australia as a Schedule 3 medication since 2004, its availability from pharmacies is not well known, nor is access from other primary health care providers.

The authors argued that the lack of knowledge about EC may lead to its underutilisation and underlines the need for future educational strategies about EC as well as the need for health professionals who provide contraceptive services to discuss EC with clients. Health promotion campaigns which are both general as well as gender-specific may improve overall community knowledge about this method of contraception.

School of Nursing and Midwifery, University of South Australia, Australia.

Emergency contraception - knowledge and attitudes in a group of Australian university students. Calabretto H. Australian and New Zealand Journal of Public Health. 2009 Jun;33(3):234-9. 

USA: Towards a multidimensional measure of pregnancy intentions

The authors used a variety of exploratory statistical methods to examine measures of pregnancy intention in the 2002 National Survey of Family Growth. From Studies in Family Planning.

The authors state that widely used dichotomous categorical measures of pregnancy intentions do not represent well the complexity of factors involved in women’s intentions. They used a variety of exploratory statistical methods to examine measures of pregnancy intention in the 2002 National Survey of Family Growth (N = 3,032 pregnancies).

Factor analyses identified two key dimensions of pregnancy intentions (desire and mistiming) and two smaller nondimensional categories (overdue and don’t care). Desire included both affective and cognitive variables, as well as partner-specific factors. Similar pregnancy-intention dimensions were found for adolescent and adult women, across socioeconomic status, and among racial and ethnic groups. Both desire and mistiming were highly predictive of the decision to abort or continue the pregnancy.

The authors note that these analyses strongly support prior demographic thinking about the importance of both the timing of pregnancy and wanting a baby, but suggest that multidimensional rather than simple categorical measures of pregnancy intentions should be used.

Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Avenue, B2, New York, NY 10032, USA.

Toward a multidimensional measure of pregnancy intentions: evidence from the United States. Santelli JS, Lindberg LD, Orr MG, Finer LB, Speizer I. Studies in Family Planning. 2009 Jun;40(2):87-100.