20 July 2008

The Future of Abortion: Controversies and Care

Summary of the BPAS conference held in central London, 25-26 June 2008.

This two-day conference marked the fortieth anniversary of BPAS, Britain’s leading abortion provider and a significant voice in policy developments and media debates. The event took place in the midst of a major Parliamentary debate about amending the British abortion law, and brought together doctors, nurses, commissioners, politicians, philosophers, journalists, campaigners and abortion providers from across Europe and the USA.

Presentations were from leading international and UK experts in abortion and sexual health services with the intention of stimulating debate and presenting best practice in service delivery. The conference was opened by the Rt Hon Dawn Primarolo MP, Minister of State for Public Health. Many issues were discussed. Four main themes emerged:

  • Abortion is a fact of modern life.

  • A good abortion service puts the woman to be treated at the centre and is part of a “joined up” sexual health service.

  • Abortion law should reflect developments in science and international clinical practice.

  • The future of abortion should be determined by an honest, ongoing and rigorous debate.

    Abortion is a fact of life

    Opening the conference, the Rt Hon Dawn Primarolo MP, Minister of State for Public Health:

  • Recognised the role played by bpas in lobbying Parliament ahead of the vote on the Abortion Act and the forthcoming Parliamentary debate, ‘clearly putting across the challenges and issues faced by women.’
  • Affirmed the government’s view that the Abortion Act is working as intended.
  • Announced a new funding of £6 million towards sexual health provision in further education sites over three years.

    Ann Furedi, chief executive of BPAS:

  • Argued that we should not be concerned that the number of abortions has increased as access to services has improved. Women today want and expect to have sex without having to become mothers, and this implies a seriousness about parenthood that should be welcomed.
  • Stressed the need for abortion as a back-up to contraception, evidenced by the extent of contraceptive failure.
  • Noted that abortion is an accepted part of life - illustrated by the presence of a large banner outside the conference centre proclaiming ‘The Future of Abortion’, and the absence of any protestors.

    Discussing the issue of ‘repeat abortion’, Dr Sam Rowlands of Warwick Medical School:

  • Demonstrated that the proportion of repeat abortions is a predictable consequence of women having access to legal abortion over the course of their whole reproductive life.
  • Argued that there is no basis for viewing the population of women who have repeat abortions as any different to those who have one abortion.

    The presentation by Professor James Trussell of Princeton University, USA:

  • Noted that half of all pregnancies in the USA are unintended, and that 48% of unintended pregnancies resulted from contraceptive failure.
  • Highlighted the superior reliability of Long Acting Reversible Contraceptives (LARCs) – ‘fit and forget’ methods that women do not have to think about taking every day. This generated considerable media coverage, with headlines such as ‘The Pill “has had its day as an effective contraceptive”’ (The Times (London))

    Addressing the question ‘what use is emergency contraception?’, Kate Guthrie, clinical director of Hull and East Riding Sexual and Reproductive Healthcare Partnership:

  • Examined research showing that increased access to EC does not reduce pregnancy and abortion rates.
  • Argued that the public health impact of EC should not be over-sold, but that the benefit to individuals should be stressed, as ‘everyone deserves a second chance to prevent an unintended pregnancy’.

    A good abortion service puts the woman to be treated at the centre and is part of a “joined up” sexual health service.

    Chris Plummer of bpas:

  • Discussed the shift in British abortion provision from providing a service from a delivery viewpoint, using private clinics, to contracting from a purchaser viewpoint, using public money via the NHS.
  • Suggested that the future of abortion care is client-focused: offering women as much choice as possible, and managing expectations where compromises are needed.
  • Acknowledged that many women will not have a real choice in some aspects of abortion provision to them: but that may not matter ‘if compromises are considered and can be explained, and if customer focus, care and kindness are at the heart of everything that we do.’

    Simon Henning, sexual health network coordinator for Cheshire and Merseyside PCT, discussed the challenges involved in commissioning sexual health and abortion services, including:

  • Commissioners working in isolation;
  • Competing agendas and targets within the sexual health portfolio;
  • Communication breakdown between commissioners and providers.

    Donagh Stenson of bpas drew upon the organisation’s 40 years of experience to suggest ‘what makes a good contract’, including:

  • Commissioning abortion services as part of a robust sexual health strategy;
  • Providing a real choice of provider;
  • Clear and easy referral pathways;
  • Client participation.

    Stenson drew attention to innovations such as offering Chlamydia testing online, which show how willingness to challenge the status quo can result in a better service.

    Reviewing the National Sexual Health Strategy, Baroness Gould of Potternewton, chair of the Independent Advisory Group on Sexual Health & HIV, situated abortion care firmly within a broad approach to contraception provision and the treatment of STIs, emphasising the need to provide a seamless service.

    The emphasis on providing a woman-centred service was endorsed from a clinical perspective. Dr Christian Fiala, a specialist in obstetrics and gynaecology in Vienna, Austria, described the historic shift in abortion care from ‘women’s domination’ to ‘respecting women’, and from ‘decision-based evidence-making’ to ‘evidence-based decision-making’. 

    Discussing possible improvements in the provision of EMA, Mitchell D. Creinin, MD, professor of obstetrics, gynaecology and reproductive sciences at the University of Pittsburgh:

  • Drew attention to the safety and acceptability of women’s home use of misoprostol – which is permitted in several countries, but not in Britain.
  • Examined research on shortening the interval between mifepristone and misoprostol administration, which may increase acceptability for women.

    Presenting new research areas in medical and surgical abortion, Daniel Grossman, MD, of Ibis Reproductive Health:

  • Suggested that routine use of ultrasound after EMA may lead to excessive intervention at follow-up.
  • Noted that in second-trimester abortion, complications are less frequent with dilatation and evacuation (D&E) than with induction of labour, and that many women prefer D&E.

    Referring to the high proportion of second-trimester abortions carried out by D&E in the USA compared with the UK, Elena Drey, MD, EdM, of the University of California raised concerns that, despite the retention of the 24-week time limit in the British abortion law, second-trimester abortion may become ‘endangered’ through lack of public, political and medical empathy with the woman.

    Abortion law should reflect developments in science and international clinical practice

    Dr Ellie Lee of the University of Kent:

  • Drew upon her research into why women have abortions in the second trimester to show why Britain’s 24-week ‘time limit’ continues to be necessary.
  • Noted that women’s failure to realise they were pregnant (often due to contraceptive failure), and the time spent deciding whether to have an abortion, are two of many reasons why women present for abortion at later gestations.
  • Argued that affording women the time to make this decision is preferable to pushing them to decide on an earlier abortion.

    Other aspects of the UK law were discussed in relation to following international practice by permitting home use of misoprostol, and permitting nurses to carry out early medical and surgical abortions:

  • Mary Fjerstad of Planned Parenthood in reported that provision of EMA by nurses in the USA has greatly enhanced access to abortion in rural areas.
  • Sexual health advisor Kathy French argued that the UK should follow international practice by allowing nurses with the appropriate training to provide early surgical abortions, and to prescribe the abortion medication used in EMA.
  • Presenting an international perspective, Marge Berer, editor of Reproductive Health Matters, noted that research and experience show that is it safe and beneficial for trained mid-level providers to play a greater role in abortion provision.

    A panel discussion on ‘challenging abortion laws’ drew attention to the specific legal issues facing reproductive health advocates in different countries.

    The future of abortion should be determined by an honest, ongoing and rigorous debate

    Engaging with the question of how abortion providers set their personal limits on ‘how late is too late?’, Lisa H. Harris of the University of Michigan argued for ‘a new kind of abortion discourse’ that is honest about the procedures used in second-trimester, and recognises the extent to which some providers can feel ‘conflicted’ by their desire to help women in need of later abortions, balanced against their possible discomfort with the procedures they are carrying out. 

    Speaking at a lively evening debate asking ‘What’s so bad about abortion?’:

  • Jon O’Brien of Catholics for Choice argued that Catholics have a duty to follow their own consciences, and should not be forced to follow the teachings of the Church.
  • Josephine Quintavalle of Comment on Reproductive Ethics argued that abortion is an ‘intrinsically illicit’ choice, and doubted the possibility of the pro-choice and anti-abortion movements finding common ground.
  • The journalist Dominic Lawson thanked BPAS for providing a much-needed dialogue and wondered how one balances the rights of a woman and those of an unborn child.
  • Ann Furedi, chief executive of BPAS, argued she accords the embryo/fetus some value – abortion is not like a tonsillectomy and BPAS’ clients know this too. But abortion ‘doesn’t take place in the abstract’, and ‘I don’t accord that life that is not yet aware it is alive the same value as a woman’s.’

    The importance of self-awareness in determining the value of life was central to the presentations given by Dr Stuart Derbyshire of Birmingham University, and Professor John Harris of the University of Manchester. Harris argued that to have a view on the ethics of abortion is to have an answer as to what makes life valuable. Derbyshire argued that ‘anatomical answers’ to the question of fetal pain are insufficient to address the complexity of the pain experience, which can be understood only through a broader understanding of what makes human beings develop.

    Commenting on the conference, Ann Furedi, Chief Executive of bpas, said:

    ‘We are proud to be able to host an event of this significance at an important time for abortion legislation. For us this was an opportunity to demonstrate that through providing abortion, we understand it. It was a chance to show that we do not ignore ethical concerns about the value of life and importance of conscience, but consider and address them. It was a space to discuss new developments in clinical practice and a platform to argue for the legal and regulatory frameworks that we believe would best serve women and those who provide the services they need.’

    Further information about ‘The Future of Abortion’ conference, including key presentations and speakers’ biographies, is available on the conference website.

    See here to read some of the substantial media coverage attracted by the conference.