11 March 2008

Abortion: A solution to a problem

Ann Furedi, Chief Executive of BPAS, analyses the 'problem' of Britain's rising abortion rate.

The ‘problem’ of the rising abortion rate has been the subject of much policy and media discussion in recent years. The number of abortions in Britain has been steadily increasing, reaching 193,700 in 2006. This is a source of frustration to government ministers because it is happening at the same time as a concerted drive to implement a sexual health strategy to reduce the number of abortions, which has meant that many more resources are being put into reducing the need for abortion.


What has also emerged as a source of distress to policymakers is that the number of women having ‘repeat’ abortions also seems to be increasing: almost one third of women under the age of 25 who have one abortion report that they have had one previously. This is despite the fact that a wider range of contraception is available, and the current policy to encourage the use of the long-acting reversible methods of contraception (LARCs).


Why is there a continuing high rate of abortion? In my view it is quite simple: there are a lot of people out there having sex who don’t want to have children. This might sound facetious but it is not. In Britain today there is a clearly-defined trend for women to delay the age at which they start to have children. In the mid-1970s, women were on average starting their families in their mid-twenties - now the age of first childbirth is in the late twenties, and the average age at which women have children has reached 29. This means that there are a lot of people who are sexually active, possibly in ongoing relationships, possibly living with partners, who simply do not want to factor in a child at this point in their lives. It is arguable that, if women in this situation do become pregnant, they are probably much more likely these days to terminate the pregnancy than continue it to term.


There is also an increasing number of women who are choosing to remain childless altogether. One in five women is now childless at 45. There has been some discussion about whether this is to do with increased infertility, perhaps to do with an increased incidence of sexually transmitted infections, but in general statistics reflect a more conscious shift in women’s priorities: namely that many women have got many other things to do in their lives, and they do not particularly want to have any family at all at any time. So it puts them in a situation where they are more likely to terminate a pregnancy.


I would argue that we have a large cohort of people who either don’t want to have children or don’t want to have children at this particular time. As a society, we have a very high expectation of family planning and birth control: we expect to be able to decide when to have children, there is a far greater sense of reproductive choice than there was in the past, and in Britain and America certainly, there is a strong sense of the need for parents to be responsible for their children. The popular press is full of discussion about the ‘problem’ of parents who do not pay enough attention to their children, who do not think carefully enough about their needs, and this illustrates a general climate in which parenting is seen to be something that should be taken very seriously, and opted into with a great deal of forethought. The idea that you would become a parent because a condom split is something that people don’t generally find very acceptable; and in this context abortion is seen as a responsible decision.


Abortion and parental responsibility


The Times (London) columnist Caitlin Moran argued this point eloquently in April 2007, in an article headlined ‘Abortion: why it’s the ultimate motherly act’. ‘My belief in the ultimate sociological, emotional and practical necessity for abortion [became] even stronger after I had my two children,’ she wrote. ‘It is only after you have had a nine-month pregnancy, laboured to get the child out, fed it, cared for it, sat with it until 3am, risen with it at 6am, swooned with love for it and been reduced to furious tears by it that you really understand just how important it is for a child to be wanted. And, possibly even more importantly, to be wanted by a reasonably sane, stable mother.’


Moran’s own abortion was, she says, ‘one of the least difficult decisions of my life’:


‘I’m not being flippant when I say it took me longer to decide what work-tops to have in the kitchen than whether I was prepared to spend the rest of my life being responsible for a further human being…While there was, of course, every chance that I might eventually be thankful for the arrival of a third child, I am, personally, not a gambler. I won’t spend £1 on the lottery, let alone take a punt on a pregnancy. The stakes are far, far too
high.’ (1)


A study by Rachel Jones and colleagues at the Guttmacher Institute in New York, published in January 2008, gives some empirical context to the viewpoint argued by Moran. (2) The study, titled ‘“I Would Want to Give My Child, Like, Everything in the World”: How Issues of Motherhood Influence Women Who Have Abortions’, began by noting that, contrary to the general perception that women who have abortions are a different group to those who are mothers, 61% of the women who have abortions in the USA already have children. Jones et al’s qualitative study of 38 women found that key reasons behind their decision to have an abortion were ‘the material responsibilities of motherhood, such as the care for their existing children, as well as the more abstract expectations of parenting, such as the desire to provide children with a good home.’ The authors further noted:


‘The women believed that children were entitled to a stable and loving family, financial security, and a high level of care and attention…The findings demonstrate reasons why women have abortions throughout their reproductive life spans and that their decisions to terminate pregnancies are often influenced by the desire to be a good parent.’


The expectation that we have of family planning, our sense of reproductive choice, and the seriousness with which we take the decision to have children, may form part of the reason why the abortion rate is going up. But these are not bad things, and certainly not developments that we would want to reverse at all. My view is that abortion is not the problem. The problem is unintended pregnancy, and abortion is the possible solution to unintended pregnancy. This begs the question, what strategies might be considered to reduce the incidence of unintended pregnancy?


Contraceptive use


One obvious strategy is to increase contraceptive use among non-users. It is the case that approximately 40% of BPAS clients say they didn’t use contraception at the time they conceived. However, we also have to acknowledge that contraception fails. People may fail to use it but it also fails; and it fails much more commonly than people tend to think.


Family planning doctors don’t like to talk about contraception failing, and prefer to concentrate on the problem of people failing to use it. But contraceptive failure is a problem that we need to face up to. Data produced by James Trussell and Lisa Wynn in the USA show the gaps that exist between the way contraception should be used, and the way it is typically used. Of the 3.1 million unintended pregnancies in the USA in 2001, Trussell and Wynn found that 48% result from contraceptive failure. (3)


It is very important to take on board the fact that contraception is fallible, because it very much affects how they think about abortion and future family planning strategies. When we at BPAS see women who have not used a method of contraception, they admit that they know where they went wrong, and often joke: ‘I’ll never let him near me again without making sure I’m properly protected’. But if someone has used contraception and it has let them down, they really don’t know where to go, which makes it very difficult for them.


For people who are using contraception, those involved in family planning may be able to help reduce their risk of unintended pregnancy by encouraging the use of LARCs, implants, and IUDs, which don’t require that they remember to use a barrier method, or take a pill every day. Emergency contraception (EC) is also a very positive development, because it can be so forgiving, allowing women to use the contraception after they have had sex.


However, I think that all of our best intentions are confounded by a number of things. People’s knowledge of, and access to, contraceptive services is one of the things that limits contraceptive use. But even here, it is important to understand that the impact of contraceptive services can be overestimated. A study published by Anna Glasier and colleagues in 2006 randomised women seeking repeat abortions between an ordinary family planning service, and a service offering specialist contraceptive advice and enhanced provision: the idea being that you could see how the quality of a family planning service and advice influenced whether or not they needed a subsequent abortion. The study found no statistical difference between the two groups at all. In fact, a slightly larger number of women in the specialised family planning services needed a repeat abortion. (4)


There have been a large number of studies about the impact of sex education on abortion rates and pregnancy rates, and these frequently tend to show that they are not having the kind of impact that family planning specialists want. They mainly make us feel good that we’re educating people more thoroughly, but they do not seem to have much impact on the abortion rate.


Sex, risk and intimacy


One area that has been rather less well studied relates to people’s perceptions of risk. Women have lots of misconceptions and misunderstandings about their fertility, their fertile period, when it is safe for them to have sex and when it is not. They also have lots of misunderstandings about contraception, and about the chances of unwanted pregnancy. We need to understand that at the end of the day, for lots of women, their motivations to use contraception may not be as high as we might think or hope, because contraception is about doing something to prevent something that might not happen anyway.


Further to this, there is an element in women’s risk-taking that is often completely forgotten by those involved in sexual health provision: which is that non-use of contraception may be hooked into something else. It may be hooked into a desire for intimacy, a desire for closeness: in other words, it may be hooked into something that is not entirely dysfunctional. We tend to think of non-contraceptive use as being dysfunctional, a thing that people shouldn’t do, whereas if we take a step back from the view of sex that is generally held by family planning doctors to imagine the woman’s viewpoint, we start to see things quite differently.


Family planning doctors, in general, see sex in terms of risk. Good sex for family planning doctors is safe, planned, under control, negotiated, responsible - all of these things. For other people, however, good sex is more to do with opportunity: it’s about it being edgy, exciting, spontaneous, passionate, lost in the moment, carried away, romantic. All of those things that people look for in their relationships mitigate against the planning, preparedness, the loss of control. For many people, relationships really are a balance of risks, and balancing risks against a desire to take things for granted, to be spontaneous.


There is some literature coming out of the gay community that looks at this sexual risk-taking in relation to gay couples who are not of equivalent HIV status. This has found that non-condom use for committed gay couples can be seen as an act of trust, closeness, intimacy, and togetherness. When we look at why people take risks with heterosexual sex, we may find that the situation is not going to be resolved by people vowing to use contraceptives better.


Those involved in sexual health provision tend to get caught up in a medical model of looking at things, which can blind us to some of the more vague and messy
aspects of human relationships that we really don’t yet understand. We shouldn’t be defensive about this, and we should challenge a lot of the received wisdom. In particular, we need to think about the subjects that we deal with from the point of view of people who are not professionals working in a particular area.


The Clintons in the USA have a great deal to answer for, in popularising the notion that abortion should be safe, legal and rare. (5) There is a very easy way to make abortion rare, and that’s to ban it, or to take away services, or to stigmatise it so people don’t feel able have recourse to it. Do we really want to go there, as a society? We have a choice to make: either we continue to see abortion as a problem, or we allow people their moments of intimacy, we allow them to enjoy sex, and we allow them to make use of abortion as a back-up to contraception.


This is the lead article in the Spring 2008 print edition of Abortion Review. Download the print edition here.

Also read:

Why don’t abortion rates decline? by Ellie Lee

References

(1) ‘Abortion: why it’s the ultimate motherly act’. The Times (London), 13 April 13 2007

(2) Jones, RK; Frohwirth, LF; Moore, AM. ‘“I Would Want to Give My Child, Like, Everything in the World”: How Issues of Motherhood Influence Women Who Have Abortions.’ Journal of Family Issues, Vol. 29, No. 1, 79-99 (2008). 1 January 2008

(3) Trussell, J and Wynn, L. ‘Reducing unintended pregnancy in the United States.’ Contraception, V77, N1, January 2008

(4) Schunmann C, Glasier A. ‘Specialist contraceptive counselling and provision after termination of pregnancy improves uptake of long-acting methods but does not prevent repeat abortion: a randomized trial’. Human Reproduction. 2006 Sep;21(9):2296-303.

(5) Remarks by Senator Hillary Rodham Clinton to the NYS Family Planning Providers, 24 January 2005.

2008 Presidential Candidate Choice Statements. NARAL Pro-Choice America. Accessed 4 March 2008.