Event - Abortion in the US: Popularity, Politics and Practice

Carol Sanger, Professor of Law at Columbia Law School, will give the BPAS 2012 Public Lecture in London, 7 March. 

We often hear of the ‘Americanisation’ of abortion politics in the UK, but unpicking the substantive threats to women’s reproductive rights in the US can be a challenge. The 2012 bpas public lecture will explore the current state of abortion politics in the US and, at a time when abortion appears increasingly politicised in the UK, reflect on what lessons can be drawn by those keen to protect women’s reproductive autonomy elsewhere.

Professor Carol Sanger is a leading international scholar in the regulation of abortion, motherhood, and family. She is the Barbara Aronstein Black Professor of Law at Columbia Law School in New York and a Senior Research Fellow at St. Anne’s College, Oxford.

Date: Wednesday 7 March 2012

Time: 6:30pm, to be followed by discussion and a wine reception

Venue: The Medical Society of London, 11 Chandos Street, Cavendish Square, London, W1G 9EB

Please click here for a map.

Admission to this event is free but please book your place with .

UK: A ‘fast-track’ referral service for intrauterine contraception following early medical abortion

This study found that only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the family planning clinic. From Journal of Family Planning and Reproductive Health Care. 

The authors note that a ‘fast-track’ referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh.

This was case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. The main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates.

Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p=0.003), less likely to live in an area of deprivation (p=0.045) and were significantly more likely to have attended the FPC in the past (p<0.0001). Most attenders (90%; n=113) proceeded to have an intrauterine method inserted; 57% (n=64) chose the levonorgestrel intrauterine system and 43% (n=49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0-54) days.

Of those women (n=55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection.

The authors concluded that only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.

Consultant Gynaecologist, Chalmers Sexual and Reproductive Health Service, NHS Lothian, Edinburgh; Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh; and Department of Reproductive and Developmental Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.

Assessment of a ‘fast-track’ referral service for intrauterine contraception following early medical abortion. Cameron ST, Berugoda N, Johnstone A, Glasier A. Journal of Family Planning and Reproductive Health Care. 2012 Jan 31. [Epub ahead of print]

USA: The comparative safety of legal induced abortion and childbirth in the United States

This study found that the risk of death associated with childbirth is approximately 14 times higher than that with abortion, and that the overall morbidity associated with childbirth exceeds that with abortion. From Obstetrics and Gynecology. 

The study set out to assess the safety of abortion compared with childbirth.

The authors estimated mortality rates associated with live births and legal induced abortions in the United States in 1998-2005. They used data from the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System, birth certificates, and Guttmacher Institute surveys. In addition, they searched for population-based data comparing the morbidity of abortion and childbirth.

The results found that the pregnancy-associated mortality rate among women who delivered live neonates was 8.8 deaths per 100,000 live births. The mortality rate related to induced abortion was 0.6 deaths per 100,000 abortions. In the one recent comparative study of pregnancy morbidity in the United States, pregnancy-related complications were more common with childbirth than with abortion.

The authors concluded that legal induced abortion is markedly safer than childbirth. The risk of death associated with childbirth is approximately 14 times higher than that with abortion. Similarly, the overall morbidity associated with childbirth exceeds that with abortion.

Gynuity Health Projects, New York, New York; and the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.

The comparative safety of legal induced abortion and childbirth in the United States. Raymond EG, Grimes DA. Obstetrics and Gynecology. 2012 Feb;119(2 Pt 1):215-9.

USA: A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss

From Fertility and Sterility. 

This study set out to determine the cost-effectiveness of medical and surgical management of early pregnancy loss.

It involved analyses of cost, effectiveness, and incremental cost-effectiveness ratios and utilities of a multicenter trial with 652 women with first-trimester pregnancy failure randomized to medical or surgical management. The main outcome measures were cost and effectiveness of competing treatment strategies.

Cost analysis of treatment demonstrates an increased cost of US$336 for 13% increased efficacy of surgical management. This analysis was sensitive to the probability of an extra office visit, the cost of the visit, and the probability of success. When the surgical arm is divided into outpatient manual vacuum aspiration (MVA) versus inpatient electric vacuum aspiration (EVA), there is an increased cost of $745 for EVA but a decreased cost of $202 for MVA compared with medical management.

In general, MVA was found to be more cost-effective than medical management. For treatment of incomplete or inevitable abortion, medical management was found to be less costly and more efficacious. Utilities studies demonstrated that a patient would need to prefer surgery 14% less than medication for its treatment efficacy to be outweighed by the desire to avoid surgery.

The authors concluded that surgical or medical management of early pregnancy failure can be cost effective, depending on the circumstances. Surgery is cost effective and more efficacious when performed in an outpatient setting. For incomplete or inevitable abortion, medical management is cost effective and more efficacious.

North Shore University Hospital, Manhasset, New York.

A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss. Rausch M, Lorch S, Chung K, Frederick M, Zhang J, Barnhart K. Fertility and Sterility. 2012 Feb;97(2):355-360.e1. Epub 2011 Dec 21.

Italy: Abortion and the argument from potential: what we owe to the ones who might exist

The author challenges the idea that the argument from potential (AFP) represents a valid moral objection to abortion. From Journal of Medicine and Philosophy.

He considers the form of AFP that was defended by Hare, which holds that abortion is against the interests of the potential person who is prevented from existing. Giublini’s reply is that AFP, though not unsound by itself, does not apply to the issue of abortion.

The reason is that AFP only works in the cases of so-called same number and same people choices, but it falsely presupposes that abortion is such a kind of choice.

This refutation of AFP implies that (1) abortion is not only morally permissible but sometimes even morally mandatory and (2) abortion is morally permissible even when the potential person’s life is foreseen to be worth living.

University of Milan, Department of Philosophy, 20122 Milan, Italy. .

Abortion and the argument from potential: what we owe to the ones who might exist. Giubilini A. Journal of Medicine and Philosophy. 2012 Feb;37(1):49-59. Epub 2012 Jan 11.

UK: Contraception in obese older women

The authors note that the prevalence of obesity and the high rates of contraceptive use amongst older women mean that any increase in associated risk is likely to be of public health concern. From Maturitas. 

The authors note that obesity is increasing in most western countries and rises significantly with age. Obese women are as sexually active as women of normal weight, and new sexual relationships in the older reproductive years are becoming more commonplace and still require effective contraception.

Continuation of pregnancy in a woman over 40 carries health risks which are exacerbated by the presence of obesity. A high proportion of pregnancies in women over 40 are unplanned and end in therapeutic abortion. The prevalence of obesity and the high rates of contraceptive use amongst older women mean that any increase in associated risk is likely to be of public health concern.

There are very few data on the specific risks of contraceptive use in obese older women. As fertility declines with age, all methods become increasingly effective. No single method is contraindicated by age alone but particular caution is required where the use of oestrogen containing preparations is considered as the risks associated with oestrogen are all also independently associated with increasing age and body mass index.

Non-oestrogen containing methods are available, whether hormonal, barrier or surgical, which are effective, acceptable and safer in the obese older woman. Some methods of contraception may indeed have particular non-contraceptive benefits for this population.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

NHS Lothian Sexual and Reproductive Health Service, Chalmers Centre for Sexual Health, Edinburgh, UK.

Contraception in obese older women. Cochrane RA, Gebbie AE, Loudon JC. Maturitas. 2012 Jan 10. [Epub ahead of print]

USA: How women anticipate coping after an abortion

From Contraception. 

The authors note that there has been some study of women’s emotional and psychological well-being after an abortion but no research into women’s expectations, at the time of seeking an abortion, of how they will cope after the abortion.

Researchers abstracted counselling needs assessment forms of 5109 women who sought an abortion at a clinic in 2008.

The results found that the most common emotions that women anticipate feeling after their abortion are relieved (63%) and confident (52%). A significant minority anticipate feeling a little sad (24%) and a little guilty (21%); 3.4% anticipate poor coping. Women with fetal abnormalities, women who do not have high confidence in their decision, women who have spiritual concerns about abortion, women with a history of depression, women who feel that they were pushed into having an abortion and teenagers are more likely to anticipate poor coping postabortion.

The authors concluded that the vast majority of women expect to cope well after their abortion. A small number make the decision to terminate their pregnancies even though they anticipate difficulty coping after the procedure.

How women anticipate coping after an abortion. Foster DG, Gould H, Kimport K. Contraception. 2011 Dec 14. [Epub ahead of print]

Copyright © 2011 Elsevier Inc. All rights reserved.

UK: Shadow health minister resigns from abortion consultation

Diane Abbott has resigned from a cross-party group on counselling given to pregnant women by abortion providers, criticising it as a “front” for those who want it outlawed, BBC News Online reports.

The group of 10 MPs, including Health Minister Anne Milton, was set up after the Commons voted last September against proposals by Ms Dorries that would have stopped abortion providers offering counselling to pregnant women. The government said at the time that it would look at ways of incorporating the “spirit” of the proposals in new regulations - and a consultation is due to be launched.

After she resigned, Ms Abbott, the MP for Hackney North and Shoreditch, wrote in a letter to Ms Milton: “I entered into the meetings in good faith. I was genuinely interested in improving the quality of counselling available to women. But I now believe the ‘consultation’ will be a front for driving through the anti-choice lobbyists’ preferred option without legislation or a debate on the floor of the House.”

In a statement, Ms Abbott said there was “no doubt which option the government wants to drive through” on abortion counselling. “The talks that have taken place have been little more than window dressing for what is an aggressive, anti-choice campaign and I am walking away from them,” she said.

But Nadine Dorries, MP for Mid-Bedfordshire said her proposals had “almost no support” among its members and “overwhelmingly people around the table are opposed to what I’m trying to do”. She added that Ms Abbott had “no clue” about what had gone on at the group’s meetings because she had only attended two out of three events.

In a statement, Ms Milton said: “It’s disappointing when anyone walks away from constructive talks on such an important issue. Talks are continuing encompassing the wide range of views on abortion. I believe we have all been encouraged about how constructive they have been and how well the meetings are progressing.”

But Ann Furedi, chief executive of the charity BPAS, which provides abortions, said: “It is shocking that the minister and officials can disregard so blatantly the advice they have received from those who provide care to pursue the ideologically-driven demands of a handful of MPs who know nothing of how services are run - and have made no effort to find out.

“It is wrong for an important aspect of care to be politicised in this way. We are frankly stunned that officials can even consider dismantling the existing care-pathways which have developed in response to what women want and need, and that they have approved and regulated without any concern until Nadine Dorries tabled her amendment.”

MPs do not have to follow party lines on abortion, as it is considered an issue of conscience, BBC New Online reports.

Diane Abbott quits MPs’ abortion counselling group. BBC News Online, 26 January 2012

Also read:

Ministers press on with controversial abortion changes. Sunday Telegraph, 21 January 2012

bpas briefing: Abortion Providers and Pregnancy Advice. Abortion Review, 29 June 2011

Abortion Review topic archive: Abortion counselling

USA: Using a simulated patient to assess referral for abortion services

The objective of this study was to determine the quality and quantity of referrals for abortion services from reproductive health care facilities that do not provide abortion services. From Journal of Family Planning and Reproductive Health Care. 

The authors note that women seeking abortion services need to access services in a timely fashion. Quick and appropriate referrals to abortion providers are critical to this process.

The objective of this study was to determine the quality and quantity of referrals for abortion services from reproductive health care facilities that do not provide abortion services. USA states were ranked by restrictiveness of abortion, and a simulated patient made calls to the five most and six least restrictive states. Referrals were considered direct if the name or telephone number of a facility that provided abortion services was given; indirect when Planned Parenthood was suggested without additional details; and inappropriate if the referral did not provide abortion services.

Of 142 calls, 77 (52.4%) were made to least restrictive states and 62 (45.8%) were made to most restrictive states. Among all calls, even after prompting staff members for a referral, 45.8% resulted in a direct referral, 19.0% resulted in an indirect referral, 8.5% resulted in an inappropriate referral and 26.8% resulted in no referral. Facilities in least restrictive states were significantly more likely to provide unprompted direct referrals (p=0.006) and significantly less likely to provide no referral (p<0.001) than facilities in most restrictive states, though these differences disappeared after prompting the staff member to provide a referral.

The authors concluded that a simulated patient received a direct referral for abortion services less than half the time, even after prompting a staff member to provide one. All facilities providing women's health care should have appropriate referrals readily available for patients seeking abortion services.

Clinical Research Assistant, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Using a simulated patient to assess referral for abortion services in the USA. Dodge LE, Haider S, Hacker MR. Journal of Family Planning and Reproductive Health Care. 2012 Jan 16. [Epub ahead of print]

UK: Abortion counselling reform back on the agenda

The Government is pressing ahead with changes that could see women considering abortion given the right to ‘independent counselling’ - despite publicly backing down last year, the Sunday Telegraph reports. 

The Department of Health (DoH) has drawn up plans to reform radically the assistance given to thousands of women with crisis pregnancies. Among them is a proposal to place abortion providers under a legal obligation to offer women access to independent counselling, stripping them from providing any “in-house” service.

Critics of the existing system say the counselling which is offered by the clinics is biased, because their funding from the state depends on the number of terminations they carry out. The services deny bias - and say that sending women elsewhere could delay the process, meaning that for some a decision to end a pregnancy could come too late.

Last September, attempts to introduce such a change in Parliament failed, amid clashes between pro-choice and pro-life campaigners and within the Coalition.

The Government had indicated support for the amendment, tabled by Nadine Dorries, a backbench Conservative MP, but days before the vote, Downing Street said David Cameron said he would not back it.

The Liberal Democrats took credit for the apparent change of stance, with party sources saying Nick Clegg, their leader, had “made plain” his opposition. However, since then, Anne Milton, the health minister, has been working with DoH civil servants behind the scenes on plans to alter the system dramatically, the Sunday Telegraph reports.

Draft proposals will set out three options. The most radical change would see abortion clinics, such as those run by the British Pregnancy Advisory Service (BPAS) and Marie Stopes International, barred from providing counselling, and under a legal duty to refer women seeking it to an independent service - as had been laid out in Mrs Dorries’ amendment.

An second option is for a system of “voluntary registration”. This would would mean any organisation offering counselling to women with a crisis pregnancy would have to meet minimum standards, and only use appropriately-trained counsellors.

A cross-party group of 10 MPs which has held secret talks over the proposals has reportedly become deeply divided about whether organisations running such servicse should be required to declare any ethical stance - such as holding pro-life beliefs. If that demand is made, some pro-life campaigners are likely to argue that abortion clinics would have to declare a financial interest in carrying out terminations.

A third option, to retain the current, is also detailed in the DoH policy paper, despite claims that it would mean a “postcode lottery” remained in the standard of care.

Ministers are braced for fierce debate over the proposals, which are due to form a Department of Health consultation, likely to begin next month.

Mrs Dorries, who is on the cross-party group of MPs, said that the position reached was “an absolute victory for women” and that independent counselling would mean more support for the most vulnerable.

The MP said: “For the past fifty years, well educated, articulate women have known exactly what they want. They have accessed abortion, and been supported by friends and family - and for those women this will mean no change. For thousands of vulnerable women, the abortion decision is taken when overwhelming practical pressure meets emotional turmoil and this is why the offer of independent counselling is so important - as it is this group of women who will probably accept it.”

Frank Field, the Labour MP, who is also on the group, said he was keen to see a clear division made between services which carry out terminations, and those counselling women with crisis pregnancies. He said: “There is no other sphere of life in which we accept that the same people giving advice are those selling the product. We don’t do it with pensions, I cannot see how it is acceptable to do it with abortions.”

In August, the Sunday Telegraph disclosed the Government’s plans to consult on independent counselling for women contemplating abortion, just ahead of a Commons vote on an amendment by Mrs Dorries. Initially, the Government indicated support for the MP’s proposal - but this was withdrawn the week before the vote, following a backlash from pro-choice campaigners, abortion clinics, and Liberal Democrats, including Mr Clegg. In the Parliamentary debate, Frank Field withdrew his own support for the amendment.

Although votes on abortion are always treated as a matter of individual conscience, and subject to a free vote, pressure was then heaped on all Coaltion MPs to follow their leaders. In an unprecedented step, Mrs Milton wrote to them just days before the free vote, advising them that no health minister would back the amendment. The vote on the amendment was lost by 118 votes to 368.

Ann Furedi, chief executive of BPAS, said she was “appalled” to hear about the options which had been drawn up, and stated that she had been given repeated assurances from DoH officials that abortion clinics would not be barred from providing counselling services.

She said: “The point is that you cannot parcel out counselling; it needs to be something that is on offer at any stage when a woman considering ending or continuing a pregnancy might want it. My concern is that this whole situation has been politically driven, and that the consequences could be hugely damaging to the service which is provided to women.”

A spokesman for the DoH said: “Work is under way to develop proposals so women can access independent counselling but no decisions have yet been taken. It’s crucial that women considering an abortion get the best advice and support available so they can make the right decision for them. We will consult on this publicly later this year.”

Ministers press on with controversial abortion changes. Sunday Telegraph, 21 January 2012

Also read:

UK: Dorries amendment fails spectacularly. Abortion Review, 7 September 2011

bpas briefing: Abortion Providers and Pregnancy Advice. Abortion Review, 29 June 2011

Abortion Review topic archive: Abortion counselling

Israel: Pre-emptive effect of ibuprofen versus placebo on medical abortion

This study set out to determine the efficacy of pre-emptive administration of the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen vs. a placebo on pain relief during medical abortion and to evaluate whether NSAIDs interfere with the action of misoprostol. From Fertility and Sterility.

This was a prospective, double-blind, randomized, controlled study, set in a university-affiliated tertiary hospital, involving sixty-one women who underwent first-trimester termination of pregnancy.

Patients received 600 mg mifepristone orally, followed by 400 μg oral misoprostol 2 days later. They were randomised to receive pre-emptively two tablets of 400 mg ibuprofen orally or a placebo, when taking the misoprostol. The patients completed a questionnaire about side effects and pain score and returned for an ultrasound follow-up examination 10-14 days after the medical abortion.

The main outcome measure was significant pain, assessed by the need for additional analgesia, and failure rates, defined by a need for surgical intervention.

Pre-emptive ibuprofen treatment was found to be more effective than a placebo in pain prevention, as determined by a significantly lower need for additional analgesia: 11 of 29 (38%) vs. 25 of 32 (78%), respectively. Treatment failure rate was not statistically different between the ibuprofen and placebo groups: 4 of 28 (14.2%) vs. 3 of 31 (9.7%), respectively. History of menstrual pain was predictive for the need of additional analgesia.

The authors concluded that pre-emptive use of ibuprofen had a statistically significant beneficial effect on the need for pain relief during a mifepristone and misoprostol regimen for medical abortion. Ibuprofen did not adversely affect the outcome of medical abortion. CLINICAL

TRIAL REGISTRATION NUMBER: NCT00997074.

Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, affiliated with the Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel.

Pre-emptive effect of ibuprofen versus placebo on pain relief and success rates of medical abortion: a double-blind, randomized, controlled study. Avraham S, Gat I, Duvdevani NR, Haas J, Frenkel Y, Seidman DS. Fertility and Sterility. 2012 Jan 19. [Epub ahead of print]

UK: Advertising rules allow private abortion clinics to advertise

Private clinics that charge for pregnancy services including abortions will be able to advertise on television and radio under new rules.

The Broadcast Committee of Advertising Practice (BCAP) said there was no justification for barring clinics offering post-conception advice services, BBC News Online reports.

BCAP said the adverts would be allowed as long as they were not harmful, offensive or misleading. The new rules take effect on 30 April.

Pregnancy clinics that run on a not-for-profit basis are already allowed to advertise on television and radio.

In a statement, BCAP said existing rules on broadcast advertising would ensure general audiences were be robustly protected from harm or offence once the restrictions were removed. It said it held a full public consultation last year but did not receive any response from the Department for Culture, Media and Sport or the Department of Health.

Clinics which do not directly refer women for terminations will have to make that clear in their advertising under the new rules. The Committee of Advertising Practice (CAP) said this was on strong public health grounds. This follows concerns, reported in the Guardian last year, about the ways in which crisis pregnancy centres established by opponents of abortion can mislead women about the services they provide.

Spokesman Matt Wilson said: “There is not going to be some sort of free-for-all saying ‘Come to us to get an abortion’. They are not there to promote abortion, they have to promote an array of services. It is about being responsible, and commercial pro-life pregnancy services will now be able to advertise too.”

Darinka Aleksic, from the pro-choice group Abortion Rights, said: “Surveys tell us that fewer than half of the UK population know where to turn when they are faced with an unplanned pregnancy - apart from going to their GP - and a lot of women, especially young women, they’re not comfortable about talking to their regular GP about this. So it’s really important that they have access to objective, accurate information about all their options when they’re facing unplanned pregnancy and that includes parenting and adoption as well as abortion.”

However, Conservative MP Nadine Dorries said the move would make having a termination seem “as easy as having your lunch”.

“What this is actually going to do is desensitise what abortion is and the seriousness of it,” she told the Daily Mail. “That may be great for articulate, well-educated women who know exactly what they want but the more vulnerable woman who is in emotional turmoil is going to be badly damaged. Broadcasters will be making profit through advertising revenue off the back of a service which ends life. It’s appalling.”

Both pro-life and groups which offer abortion advice say this ruling will not see a surge of advertisements on television because more abortions are carried out by groups on behalf of the NHS. In 2010, 96% of abortions were funded by the NHS, 51% of which were carried out by independent clinics on behalf of the service.

The Society for the Protection of Unborn Children (SPUC), a pro-life group, said advertising would be dominated by groups such as the British Pregnancy Advisory Services (BPAS) and Marie Stopes as they receive funds from the NHS to carry out abortions. The group added that “Marie Stopes and their ilk” should have to declare that they offer abortion or have a financial interest in it. “This decision will only serve the abortion industry’s money-spinning trade which hurts women through killing their unborn children,” added a spokesman.

A spokeswoman for BPAS said: “Unlike anti-abortion agencies, BPAS believes that whatever decision a woman makes - be that to keep or end the pregnancy - is equally valid. We are a not-for-profit charity; our only interest is in a woman making the choice that is right for her.”

CAP and BCAP are responsible for the self-regulation of the advertising industry under the watch of the Advertising Standards Authority (ASA). In 2010, the ASA rejected complaints about the first UK television advertisement by an abortion advisory organisation. The advertising watchdog said the advert for Marie Stopes, which ran on Channel 4, did not mention or advocate abortion.

Abortion clinics cleared for TV by advertising body. BBC News Online, 21 January 2012

Television WILL screen pro-abortion adverts amid storm of controversy. Daily Mail, 21 January 2012

Post-conception advice services: Regulatory Statement. Committee of Advertising Practice , 20 January 2012

UK: Investigation into crisis pregnancy centres. Abortion Review, 8 August 2011

UK: To meta-analyse or not to meta-analyse: abortion, birth and mental health

The authors argue that to further improve the mental health outcomes associated with an unwanted pregnancy we should focus practice and research on the individual needs of women with an unwanted pregnancy, rather than how the pregnancy is resolved. From British Journal of Psychiatry. 

The authors note that two recent meta-analyses claim that abortion leads to a deterioration in mental health. Previous reviews concluded that the mental health outcomes following an unwanted pregnancy are much the same whether the woman gives birth or terminates the pregnancy, although there is an increased mental health risk with an unwanted pregnancy. Meta-analysis is particularly susceptible to bias in this area.

The authors argue that physical health outcomes for women with an unwanted pregnancy have improved greatly by making abortion legal. To further improve the mental health outcomes associated with an unwanted pregnancy we should focus practice and research on the individual needs of women with an unwanted pregnancy, rather than how the pregnancy is resolved.

Sheffield Health and Social Care (NHS) Foundation Trust, Fulwood House, Old Fulwood Road, Sheffield S10 3TH, UK.

To meta-analyse or not to meta-analyse: abortion, birth and mental health. Kendall T, Bird V, Cantwell R, Taylor C. British Journal of Psychiatry. 2012 Jan;200:12-4.

New Zealand: Impact of long-acting reversible contraception on return for repeat abortion

The objective of the study was to determine the rate of return for repeat abortion in relation to postabortion contraceptive method choice 24 months onward from an intervention study. From American Journal of Obstetrics and Gynecology. 

This was a prospective cohort study involving a hospital note search for 510 women 24 months after an abortion.

Women using long-acting reversible contraceptive (LARC) methods (intrauterine device [IUD] and depot medroxyprogesterone acetate) had significantly lower return rates for repeat abortion (6.45%; 95% confidence interval [CI], 4.0-9.8) than non-LARC users, of whom 14.5% returned (95% CI, 9.9-20.2). A Cox proportional hazard analysis showed that the postabortion method choice was significantly related to the likelihood of returning for a repeat abortion (P = .002), controlling for major demographic factors and previous pregnancy history. Using the pill as a reference group for risk of repeat abortion, the IUD hazard ratio (HR) was 0.36 (95% CI, 0.17-0.77), the depot medroxyprogesterone acetate HR was 0.55 (95% CI, 0.21-1.45), and the HR for all other methods was 1.8 (95% CI, 0.83-3.92).

The authors concluded that this study provides strong support for the promotion of immediate postabortion access to LARC methods (particularly intrauterine devices) to prevent repeat abortion.

Department of Primary Health Care and General Practice, Women’s Health Research Centre, University of Otago, Wellington, New Zealand.

Impact of long-acting reversible contraception on return for repeat abortion. Rose SB, Lawton BA. American Journal of Obstetrics and Gynecology. 2012 Jan;206(1):37.e1-6. Epub 2011 Jul 13.

A roundtable discussion of this study is published here:

Discussion: ‘Long-acting reversible contraception and repeat abortion’ by Rose et al. Macones GA, Odibo A, Cahill A. American Journal of Obstetrics and Gynecology.  2012 Jan;206(1):e10-1. Epub 2011 Nov 18.

USA: Music as an auxiliary analgesic during first trimester surgical abortion

The authors note that music has served as an auxiliary analgesic in perioperative settings. This study evaluates the impact of intraoperative music added to routine pain control measures during first trimester surgical abortion. From Contraception. 

The authors analysed data from 101 women randomized to undergo abortion with routine pain control measures only (ibuprofen and paracervical block) or with the addition of intraoperative music via headphones. The primary outcome was the change in preoperative and postoperative pain scores on a 100-mm visual analog scale. Secondary outcomes included change in anxiety and vital signs, and satisfaction.

Baseline characteristics were similar between groups. The magnitude of increase in pain scores was greater in the intervention than in the control group (+51.0 mm versus +39.3 mm, p=.045). Overall pain control was rated as good or very good by 70% of the intervention and 75% of the control group (p=.65).

The authors concluded that intraoperative music added to routine pain control measures increases pain reported during abortion.

Department of Obstetrics and Gynecology, University of California at Irvine Medical Center, Orange, CA 92868, USA.

Music as an auxiliary analgesic during first trimester surgical abortion: a randomized controlled trial. Guerrero JM, Castaño PM, Schmidt EO, Rosario L, Westhoff CL. Contraception. 2012 Jan 10. [Epub ahead of print]

Copyright © 2012 Elsevier Inc. All rights reserved.

USA: Induced abortion: incidence and trends worldwide from 1995 to 2008

The study found that the global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. From the Lancet. 

The authors note that data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003.

The authors used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. They used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. They assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology, and used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008.

The study found that the global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

The authors argue that the substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

FUNDING: UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Copyright © 2012 Elsevier Ltd. All rights reserved.

Guttmacher Institute, New York, NY, USA.

Induced abortion: incidence and trends worldwide from 1995 to 2008. Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Lancet. 2012 Jan 18. [Epub ahead of print]

Effect of bacterial vaginosis on the pharmacokinetics of misoprostol in early pregnancy

From Human Reproduction. 

The authors note that misoprostol has been shown to be an effective agent for cervical ripening and termination of early pregnancy especially when administered vaginally. The authors’ objective was to evaluate whether bacterial vaginosis (BV) affected the pharmacokinetics of vaginally administered misoprostol during early pregnancy.

Ten women with BV and 10 healthy women requesting medical abortion up to 9 weeks of pregnancy were administered 200 mg mifepristone followed 24-48 h later by a single dose of 800 µg misoprostol vaginally. Blood samples were taken before (0 h) and 0.5, 1, 2, 3 and 4 h after misoprostol administration. Misoprostol acid was determined in serum samples using liquid chromatography/tandem mass spectrometry.

All women with BV had a vaginal pH > 4.7. The mean bioavailability measured as the area under the curve (AUC) and maximum concentration (C(max)) appeared higher in the control than in the BV group (1458.7 versus 878.1 pg h/ml) and (630.7 versus 342.5 pg/ml), respectively, but did not achieve statistical significance and there was no other significant difference in the pharmacokinetics between the two groups. However, if two women with vaginal pH > 4.7 were excluded from the control group the difference in AUC(240) (1359 versus 878.1 pgh/ml) reached statistical significance (P = 0.048).

The authors concluded that BV had an effect on pharmacokinetics of vaginally administered misoprostol in early pregnancy. However, the results should be interpreted with caution due to the small sample size and marked individual variations.

Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet/Karolinska University Hospital, 17176 Stockholm, Sweden.

Effect of bacterial vaginosis on the pharmacokinetics of misoprostol in early pregnancy. Sioutas A, Sandström A, Fiala C, Watzer B, Schweer H, Gemzell-Danielsson K. Human Reproduction. 2012 Feb;27(2):388-93. Epub 2011 Nov 28.

USA: The effect of perioperative ketorolac on pain control in pregnancy termination

The study was conducted to evaluate the effect of perioperative ketorolac on pain associated with first-trimester aspiration abortion. From Contraception.

A double-blind, randomized, placebo-controlled trial was performed involving pregnant women up to 14 weeks’ gestation who desired pregnancy termination. Subjects were randomized to receive ketorolac 30 mg intravenously (n=31) or placebo (n=45) at the time of induction of anesthesia. Postoperative pain was assessed using a visual analog scale (VAS). The primary outcome was pain control as determined by VAS score. Secondary measures of patient use of supplemental postoperative pain medications and patient satisfaction were assessed.

Subjects in the ketorolac group had lower postoperative pain scores on the VAS at all time points compared to the placebo group, but the difference was not statistically significant. The ketorolac group used less postoperative acetaminophen compared to the placebo group (6.5% versus 35.6%), respectively. Subjects in the placebo group and the ketorolac group had similar requirements for postoperative narcotics in the recovery room (22.2% versus 19.4%). Patient satisfaction with pain level was equivalent between the groups at all postoperative end points. There was no observed difference in perioperative blood loss observed between the two groups.

The authors concluded that perioperative ketorolac has the same effect on postoperative pain as determined by VAS as placebo. The use of ketorolac at the 30-mg dose cannot be recommended for better pain control for patients undergoing first-trimester pregnancy termination by suction curettage. The only positive effect of the use of ketorolac compared to placebo was a reduction in the use of acetaminophen. Ketorolac use does not appear to change blood loss in the operating room or through postoperative day 1 compared to placebo.

Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA.

The effect of perioperative ketorolac on pain control in pregnancy termination. Roche NE, Li D, James D, Fechner A, Tilak V. Contraception. 2012 Mar;85(3):299-303. Epub 2011 Nov 30.

Copyright © 2012 Elsevier Inc. All rights reserved.

Clinical Update: Feticide

By Patricia A. Lohr, Medical Director, BPAS.

Q) What is feticide?

From a medical perspective, this term refers to modalities to induce fetal demise (1). Feticide is most commonly used for selective termination of higher order gestations to twins or singletons. It is also used by some providers before medical and surgical abortion in the second and third trimesters to avoid signs of life at induction or in the belief that it makes the procedure easier and safer. Several methods have been described including intra-cardiac injection of potassium chloride, intra-amniotic injection of digoxin, and transection of the umbilical cord (2). Older methods of medical abortion employed instillation of hyperosmolar solutions such as urea, which also variably induced fetal demise.

Q) When is feticide typically used in the abortion process?

In Britain, the Royal College of Obstetricians and Gynaecologists (RCOG) has made specific recommendations about the use of feticide before medical abortion in cases of fetal abnormality (3). Its recommendations have also been applied to medical abortions for other indications (4). According to the RCOG, because the rare likelihood of a live birth increases from 21+6 weeks of gestation, feticide should be routinely offered after this gestational age to avoid this possibility. The RCOG recommends the use of intra-cardiac potassium chloride to ensure fetal asystole, which can be observed ultrasonographically typically within minutes after injection.

The usefulness of feticide before dilatation and evacuation (D&E), the commonest method of surgical abortion in the second trimester, remains a matter of debate. Cervical preparation before D&E usually occurs in the 24-48 hours before surgical evacuation and extra-mural deliveries, although rare, have been reported. Induction of fetal demise in these cases would avoid the potential for a live birth. However, advocates of feticide typically propose that the maceration of the fetus which occurs as a result of demise is beneficial because it leads to an easier, faster and safer surgical evacuation (5).

The only randomised trial comparing feticide to placebo evaluated intraamniotic digoxin and used procedure duration as a proxy for ease of abortion. With 1mg intra-amniotic digoxin, there was no difference in procedure time (p=0.60) or difficulty as reported by the surgeon (p=0.64) (6). Although the study was not designed to assess clinical outcomes, there were no differences in estimated blood loss, pain scores or complications between the groups. There are no similar studies of potassium chloride or other methods of feticide.

Q) What are the clinical skills required to administer feticide?

Most feticidal procedures are performed by intra-cardiac or intra-amniotic injections. Ultrasound evaluation prior to either allows confirmation of gestational age, evaluation of amniotic fluid level, fetal position, and placental location. Continuous ultrasound guidance is not necessary for intra-amniotic injections as confirmation of location of the needle can be assessed by drawing up a small amount of amniotic fluid into a syringe before injection of the medication. Intra-fetal or intra-cardiac injection, however, requires a greater degree of precision in needle positioning and continuous ultrasound guidance is usually employed. Ultrasound is also useful to confirm fetal asystole following potassium chloride injection.

Q) What are the advantages of using feticide from a clinical point of view?

There is some limited evidence that induced fetal demise before a medical abortion shortens the interval been the onset of the induction and expulsion of the fetus (7). In the setting of placenta praevia, bleeding may be less when feticide has been administered prior to a medical abortion (8). These effects still require testing in the context of larger, randomised trials. The randomised trial of digoxin before D&E at 20-24 weeks gestation by Jackson et al (6) reported that 92% of participants expressed a strong preference for fetal demise before the abortion. However, of those, 29% believed the injection would make the procedure easier and 19% less painful for the woman having the abortion, neither of which were proven by this study.

Q) And the disadvantages?

Extra-mural delivery of the fetus can occur in the interval between administration of feticide and initiation of a medical or surgical abortion (2). Although signs of life are avoided this is distressing and, in the case of a planned D&E, not the outcome the woman desired. Potential complications include injection site pain, amnionitis, or sepsis. Digoxin is associated with vomiting as a common side effect. One case report of a maternal cardiac arrest has been reported following potassium chloride injection (9).

Q) What would you recommend as best practice in the use of feticide?

There is currently no evidence to support the use of digoxin to facilitate increased safety with dilatation and evacuation. There is, however, evidence that its administration has the potential to cause harm (e.g., infection, vomiting, extra-mural delivery). It has recently been argued that digoxin feticide before D&E should only be provided in the context of a clinical trial aimed at assessing its benefits (10). At BPAS, we routinely perform intra-cardiac potassium chloride injections before D&E at 22+0 weeks and greater. We regularly review complications with all of our procedures and have found that, empirically, this practice is associated with an extremely low rate of complications. However, it is unknown whether it is the feticide or some other aspect of our service delivery which leads to such a strong safety profile. Ideally, this practice should be studied in a randomised trial as well.

At present, the RCOG makes a strong recommendation for the routine offer of feticide before later medical abortions, which is centred around the avoidance of resuscitation that is counter to the objective of terminating a pregnancy. Whether the balance of risks and benefits sways toward fetcide from a clinical perspective remains unclear. In addition, little is known about how patients feel about undergoing this invasive procedure which may, in and of itself, be distressing. Best practice at this stage would be to call for more and better research on the use of feticide.

Read all Patricia Lohr’s Clinical Update columns here.

References

(1) R.H. Graham et al. Understanding feticide: An analytic review. Social Science & Medicine. 2008; 66:289–300
(2) Diedrich J, Drey E; Society of Family Planning. Induction of fetal demise before abortion. Contraception. 2010 Jun;81(6):462-73.
(3) RCOG. Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales. London: RCOG, 2010.
(4) RCOG. The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7. London: RCOG, 23 November 2011
(5) Maureen Paul, Steve Lichtenberg, Lynn Borgatta, David A. Grimes, Philip G. Stubblefield, Mitchell D. Creinin, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Chichester, W. Surrey, UK: Wiley-Blackwell, 2009.
(6) Jackson RA, et al. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstetrics and Gynecology. 2001;97:471–476
(7) Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstetrics and Gynecology. 1999;94:139–141.
(8) Ruano R, et al. Second- and third-trimester therapeutic terminations of pregnancy in cases with complete placenta previa—does feticide decrease postdelivery maternal hemorrhage?. Fetal Diagnosis and Therapy. 2004;19:475–478.
(9) Coke GA, et al. Maternal cardiac arrest associated with attempted fetal injection of potassium chloride. International Journal of Obstetric Anesthesia. 2004;13:287–290
(10) Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion: Evidence and ethics. Contraception. 2011 May 26. [Epub ahead of print]

UK: Midwives in conscientious objection battle

Scotland’s largest health board has been taken to court by Catholic midwives who claim conscientious objections over abortion procedures were disregarded. 

Midwifery sisters Mary Doogan, 57, and Concepta Wood, 51, say being forced to supervise staff taking part in abortions violates their human rights, BBC News Online reports.

NHS Greater Glasgow and Clyde claims conscientious objections do not give them the right to refuse such duties.

The hearing, at the Court of Session in Edinburgh, continues.

Ms Doogan and Mrs Wood sought during a grievance procedure to have confirmation that they were not required to delegate, supervise or support staff in the participation and care of patients through “the processes of medical termination of pregnancy and feticide”. NHS Greater Glasgow and Clyde (GGC) rejected their application.

Both women have now gone to court seeking to have the ruling set aside in a judicial review, claiming that the refusal to recognise their entitlement to conscientious objection was unreasonable and violated their rights under Article 9 of the European Convention on Human Rights (ECHR) guaranteeing the right to freedom of thought, conscience and religion.

They are seeking a finding that their entitlement to conscientious objection to taking part in abortions in terms of the 1967 Abortion Act includes the right to refuse to delegate, supervise and support staff involved in such work.

The women said in their petition that they are practising Roman Catholics and: “They hold a religious belief that all human life is sacred from the moment of conception and that termination of pregnancy is a grave offence against human life.”

They maintain that they hold the belief that that their involvement in the process of termination is wrongful and an offence against God and the teachings of their church.

Ms Doogan and Mrs Wood, who are both midwifery sisters at the Southern General Hospital, in Glasgow, worked in the labour ward. Ms Doogan, from Glasgow, has been absent through ill health since 2010 as a result of the dispute, BBC News Online reports. Her colleague, from Clarkston, East Renfrewshire, has been transferred to maternity assessment work.

NHS GGC, which is contesting their action, said it recognised their right not to participate in terminations under the terms of the Abortion Act. But it maintains that it decided correctly that requiring them to delegate staff to nurse women undergoing medical terminations and to supervise and support staff undertaking that duty was lawful.

It maintains that the women’s rights to conscientious objection under the legislation does not include the right to refuse such duties. The board said that its decision respects the women’s rights under Article 9 of the ECHR.

Catholic midwives in abortion conscientious objection case. BBC News Online, 17 January 2012

India: Methotrexate: a detailed review on drug delivery and clinical aspects

From Expert Opinion on Drug Delivery. 

The authors note that uses of methotrexate (MTX) are well established for the treatment of various types of malignancy, psoriasis, rheumatological diseases and the medical termination of pregnancy. Formulation and targeting approaches for MTX with controlled release carriers, multiparticulate systems, prodrug and drug conjugates have been found to improve bioavailability, reduce adverse effects and maximize clinical efficacy, compared with conventional methods.

This exhaustive literature survey on different electronic databases covers drug delivery and clinical trials on MTX. This review deals with the challenges and achievements of controlled release, multiparticulate, prodrug and drug conjugate systems of MTX.

Expert opinion: Therapeutic drug monitoring of MTX is crucial to attain a good efficacy. In spite of the advantages of multiparticulate, prodrug and drug conjugates, clinical applications of such formulations of MTX are still under infancy. These drug delivery systems require the special attention of medical experts for its wider clinical usage, and pharmaceutical experts for its scale-up. The combination of MTX with other antineoplastic and immunosuppressants should also be subjected to clinical trials, such as the combination of misoprostol with MTX in abortion

Banaras Hindu University, Institute of Technology, Department of Pharmaceutics , Varanasi-221005 , India.

Methotrexate: a detailed review on drug delivery and clinical aspects. Khan ZA, Tripathi R, Mishra B. Expert Opinion on Drug Delivery. 2012 Jan 18. [Epub ahead of print]

New research into worldwide abortion trends

After a period of substantial decline, the global abortion rate has stalled, according to new research from the Guttmacher Institute and the World Health Organization (WHO). 

Between 1995 and 2003, the overall number of abortions per 1,000 women of childbearing age (15–44 years) dropped from 35 to 29; according to the new study, the global abortion rate in 2008 was virtually unchanged, at 28 per 1,000. This plateau coincides with a slowdown, documented by the United Nations, in contraceptive uptake, which has been especially marked in developing countries, states a press release by the Guttmacher Institute.

The researchers also found that nearly half of all abortions worldwide are unsafe, and almost all unsafe abortions occur in the developing world. The study, ‘Induced Abortion: Incidence and Trends Worldwide from 1995 to 2008’, by Gilda Sedgh et al., was published online on 18 January by The Lancet.

In the developing world, the abortion rate was 29 per 1,000 in both 2003 and 2008, after falling from 34 per 1,000 between 1995 and 2003. The situation was somewhat different in the developed world, excluding Eastern Europe, where the abortion rate was much lower, at 17 per 1,000 in 2008, having declined slightly from a rate of 20 in 1995.

“The declining abortion trend we had seen globally has stalled, and we are also seeing a growing proportion of abortions occurring in developing countries, where the procedure is often clandestine and unsafe. This is cause for concern,” says Gilda Sedgh , lead author of the study and a senior researcher at the Guttmacher Institute. “This plateau coincides with a slowdown in contraceptive uptake. Without greater investment in quality family planning services, we can expect this trend to persist.”

Research from WHO shows that complications due to unsafe abortion continued to account for an estimated 13% of all maternal deaths worldwide in 2008; almost all of these deaths occurred in developing countries. Globally, unsafe abortion accounted for 220 deaths per 100,000 procedures in 2008, 350 times the rate associated with legal induced abortions in the United States (0.6 per 100,000). Unsafe abortion is also a significant cause of ill-health: Each year approximately 8.5 million women in developing countries experience abortion complications serious enough to require medical attention, and three million of them do not receive the needed care.

“Deaths and disability related to unsafe abortion are entirely preventable, and some progress has been made in developing regions. Africa is the exception, accounting for 17% of the developing world’s population of women of childbearing age but half of all unsafe abortion–related deaths,” notes Iqbal H. Shah, of the WHO and a coauthor of the study. “Within developing countries, risks are greatest for the poorest women. They have the least access to family planning services and are the most likely to suffer the negative consequences of an unsafe procedure. Poor women also have the least access to postabortion care, when they need treatment for complications.”

The findings provide further evidence that restrictive abortion laws are not associated with lower rates of abortion. For example, the 2008 abortion rate was 29 per 1,000 women of childbearing age in Africa and 32 per 1,000 in Latin America, regions where abortion is highly restricted in almost all countries. In contrast, in Western Europe, where abortion is generally permitted on broad grounds, the rate is 12.

The Southern Africa subregion, where close to 90% of women live under South Africa’s liberal abortion law, has the lowest abortion rate in Africa, at 15 per 1,000 women. Other very low subregional rates are found in Western Europe (12) and Northern Europe (17), where both abortion and contraception are widely available either for free or at very low cost.

Eastern Europe presents a very different situation, with an abortion rate that is nearly four times that of Western Europe. This discrepancy corresponds with Eastern Europe’s relatively low levels of modern contraceptive use and low prevalence of highly effective methods such as the pill and the IUD. After a striking decline in the abortion rate between 1995 and 2003, from 90 to 44 per 1,000 women, Eastern Europe experienced virtually no change in the rate between 2003 and 2008.

LONG-TERM WORLDWIDE DECLINE IN ABORTIONS HAS STALLED: Plateau Coincides with Slowdown in What Had Been a Steady Increase in Contraceptive Use. Guttmacher Institute, 18 January 2012

Induced abortion: incidence and trends worldwide from 1995 to 2008. Dr Gilda Sedgh, Susheela Singh, Iqbal H Shah, Elisabeth Åhman, Stanley K Henshaw, Akinrinola Bankole. The Lancet, Early Online Publication, 19 January 2012. doi:10.1016/S0140-6736(11)61786-8Cite or Link Using DOI

Facts on Induced Abortion Worldwide. Guttmacher Institute, January 2012

UK: Stigma, abortion, and disclosure - findings from a qualitative study

From Journal of Sexual Medicine. 

This study qualitatively explores perceptions of women who have experienced abortion care. It explores women’s journey through abortion from confirmation of pregnancy to post-abortion. The study seeks to understand the implications of these perceptions for policy and practice.

This is a qualitative study involving in-depth semi-structured interviews with 17 women, aged between 22 and 57 years, who had undergone legal induced abortion in the UK when they were 16 years or older. Participants were not recruited under the age of 16 because of the ethical and legal complexities of interviewing minors. Additionally, 16 years was deemed to be the most appropriate age as this is the legal age of consent in the UK.

Participants were recruited from 12 community contraception and sexual health clinics in two NHS trusts, one in England and one in Wales. Participant recruitment was set at a minimum of 12 and participants were recruited on a “first come first served basis” (i.e., the first 12 who contacted the researcher). The number of participants was raised to seventeen as this was the number deemed to be the most suitable for data saturation in this particular qualitative research.

Women in this study understood abortion as highly taboo and a potentially personally stigmatising event. These perceptions continued to affect disclosure to others, long after the abortion, and affected women’s perceptions of the response of others, including society in general, significant others, and health professionals.

The authors concluded that women’s experiences of abortion may be influenced by perceived negative social attitudes. Health professionals and abortion service providers might combat the perceived isolation of women undergoing abortion by attending not only to clinical/technical aspects of the procedure but also to women’s psychological/emotional sensitivities surrounding the event.

Glyndŵr University, Department of Nursing, Wrexham, UK Glyndŵr University, Social Inclusion Research Unit, Wrexham, UK Glyndŵr University, Centre for Health and Community Research, Wrexham, UK.

Stigma, Abortion, and Disclosure - Findings from a Qualitative Study. Astbury-Ward E, Parry O, Carnwell R. Journal of Sexual Medicine. 2012 Jan 12. doi: 10.1111/j.1743-6109.2011.02604.x. [Epub ahead of print]

© 2012 International Society for Sexual Medicine.

USA: Contraception and abortion coverage: what do primary care physicians think?

From Contraception. 

The authors note that insurance coverage for family planning services has been a highly controversial element of the US health care reform debate. Whether primary care providers (PCPs) support public and private health insurance coverage for family planning services is unknown.

PCPs in three states were surveyed regarding their opinions on health plan coverage and tax dollar use for contraception and abortion services.

The results found that almost all PCPs supported health plan coverage for contraception (96%) and use of tax dollars to cover contraception for low-income women (94%). A smaller majority supported health plan coverage for abortions (61%) and use of tax dollars to cover abortions for low-income women (63%). In adjusted models, support of health plan coverage for abortions was associated with female gender and internal medicine specialty, and support of using tax dollars for abortions for low-income women was associated with older age and internal medicine specialty.

The authors concluded that the majority of PCPs support health insurance coverage of contraception and abortion, as well as tax dollar subsidisation of contraception and abortion services for low-income women.

Division of General Internal Medicine, Penn State College of Medicine, Hershey, PA 17033, USA.

Contraception and abortion coverage: what do primary care physicians think? Chuang CH, Martenis ME, Parisi SM, Delano RE, Sobota M, Nothnagle M, Schwarz EB. Contraception. 2012 Jan 10. [Epub ahead of print]

Copyright © 2012 Elsevier Inc. All rights reserved.

Taking stock of the morning-after pill

Clare Murphy, Director of Press and Public Policy, discusses the reaction to BPAS’s Christmas campaign promoting advance prescription of the Emergency Contraceptive Pill. 

During December 2011 BPAS ran a scheme to enable women to request the morning-after pill for free over the internet so she could have it at home in advance of need over the festive period, when pharmacies and clinics might be closed. A nurse would phone her to make sure she was medically suitable, ensure it was not being requested for immediate use, and provide all the necessary information on how and when to use it – then, all things being equal, the emergency contraceptive pill (ECP) would be posted to her home address.

It was interesting to note the difference in response between the enthusiasm of the women who wanted to use the scheme (so many requests in the first 48 hours we couldn’t guarantee Xmas delivery) and that of officials, who were not so keen. The Health Secretary Andrew Lansley, who despite having his hands full with NHS reform, still found the time to express his opprobrium, noting that emergency contraception should be just ‘for emergencies, not everyday use’, and that ideally it would be available in person, so that ‘any decisions were made with the benefit of face-to-face advice’. 

It’s a bit odd to describe a woman requesting one solitary pill as someone who is planning on popping it daily - but there you go. What was however prevalent among the women who contacted us was that many had experienced difficulties obtaining the medication in the past, and appreciated being able to speak to someone over the phone who they knew was not judging them, but rather recognising that they were doing a sensible thing. They weren’t planning on being reckless, but wanted to ensure that they had immediate access to an effective way of protecting themselves against an unwanted pregnancy if they needed it. And they perhaps didn’t feel the need – or desire - for time-consuming ‘face-to-face advice’ about the decision whether or not to take the morning-after-pill should the situation arise.

You can’t help thinking that if we’d been offering Viagra free of charge to men in need we would have been slapped on the back, such is still the contradiction in attitudes towards male and female sexuality. Indeed it was interesting to compare the Telegraph’s outrage that a ‘penny-pinching NHS’ was curbing men’s sex lives by rationing erectile dysfunction drugs to two doses per month with its excoriating reaction the same week to our free morning-after pill scheme. That paper lined up no fewer than five critics, including Nadine Dorries MP, whom somehow we just can’t seem to please: she doesn’t like it when we are providing abortions, but appears equally aggrieved when we are trying to prevent the need.

The morning-after pill - much like long-acting reversible contraceptives (LARCs)- was never going to be a silver bullet to cut unwanted pregnancy. Many women do not know their contraception has failed, or believe they are at a time in their cycle when they are unlikely to get pregnant. But did we give up too quickly on it? We know that the cost, inconvenience and embarrassment of obtaining the morning-after pill can put women off obtaining it when they think their risk is low. Our own surveys show that women also worry about the health implications of using ECPs – even though post-coital contraceptives have been around for decades and there is no evidence of any long-term health consequences. But it is not surprising that women have reservations about using ECPs when all the messages around its use in this country have always been so very mixed: use it, but don’t ever need to use it.

This message needs to change. Research is currently being conducted in the USA into using post-coital contraception as a regular form of contraception for women who do not have frequent sex – a ‘before sex’ pill, if you like. It may well alter the narrative around ECP use, from being seen as something to be embarrassed about to becoming recognised as a planned, responsible, course of action. In the meantime, the morning-after pill should be viewed as a legitimate and welcome back-up for women to control their fertility as often as they need to, well deserving of its place on the contraceptive menu.

Are we making the most of the morning-after pill? This will be one of the topics for discussion at BPAS’s public conference ‘Pills in Practice: is contraception and abortion policy meeting women’s needs?’, on Friday 11 May 2012. For more information and to book a place please see here.

Read on:

UK: Morning-after pill offered free by post. Abortion Review, 6 December 2011

Pills in Practice: Is abortion and contraception policy meeting women’s needs? Announcing the BPAS public conference, to be held at the Royal Society of Medicine in central London on Friday 11 May 2012.

BPAS blog

Commentary: Is abortion and contraception policy meeting women’s needs?

By Jennie Bristow, Editor, Abortion Review.

Does current policy on abortion and contraception meet the needs of British women? This is the question that will be interrogated at BPAS’s forthcoming public conference, to be held at the Royal Society of Medicine in London on Friday 11 May 2012.

On one hand, abortion and contraception have come a long way since the 1967 Abortion Act; services are legal, provided, and funded, and control over one’s fertility has become an accepted and expected part of life. On the other hand, the extent to which arcane laws and political prejudices prevent the best use of new methods is a source of continuing frustration to service providers, and causes anxiety and inconvenience for women.

Take the development of the ‘abortion pill’, in the form of the drugs mifepristone and misoprostol. This has transformed provision of early abortion across the world, from an operation requiring a trained surgeon and a hospital bed into a service that can be led by nurses and midwives and administered by women themselves in their own homes. In theory at least, women using this method can have greater control and autonomy over when and where they have an abortion. Throughout the USA and Europe early medical abortion is routinely provided outside of hospital settings, in clinics and GP surgeries, and new research into the use of telemedicine in the USA shows the possibility of even greater flexibility in providing a safe, effective and accessible service.

Yet in Britain, the law is interpreted such that women are denied even the possibility of taking the misprostol, the second drug in the abortion pill, at home, requiring them instead to make multiple trips to clinics and to time taking their medication around the schedules of providers, rather than their own needs. This situation is starkly out of step with clinical guidance, and with practice in other countries. The importance of women’s autonomy over childbirth has been recognised over the past few decades, and steps have been taken to ‘de-medicalise’ childbirth, through promoting midwife-led care and home birth where possible, so why should abortion be so different? Isn’t it time we made the most of the skills of nurses and midwives, and took seriously women’s desire to have more control over their own bodies?

While provision of abortion in the early stages of pregnancy to healthy women has undoubtedly improved, there is a group of women for whom access is complex and restricted. This includes women seeking an abortion on grounds of fetal anomaly, who might find themselves denied a choice of abortion method or stigmatised over the perceived severity of the anomalies in question, and women with particular health conditions or high BMI. How do we ensure that the abortion and contraception services take account of the needs and circumstances of all individual women?

Another focus of discussion at the 2012 conference will be new developments in Long-Acting Reversible Contraceptives (LARCs), which offer more effective, longer-term prevention of unintended pregnancy. These methods have numerous advantages to women who want to use them; but these methods have disadvantages and side-effects that mean they may not be the ‘magic bullet’ for reducing abortion rates, or teenage pregnancy, in the way that some policymakers seem to hope. In the meantime, new thinking in the provision of more established forms of hormonal contraception, such as the pill and the morning-after pill’, seems to have stalled. How do we assess the benefits and downsides of LARCs? What might women in the future expect from contraception?

Underlying all these issues are questions to do with clinical practice, political will, ethical arguments, and medical training. In Britain, as in many other countries where abortion has been legal for more than a generation, there is a gap between women’s expectations of a service they can access, and ongoing controversies at a political level. This gap is mirrored in the problems experienced in recruiting and training a new generation of abortion doctors, nurses and midwives, without whom abortion services cannot be run, or improved.

The first in a series of events planned by BPAS on the theme of ‘The Future of Fertility’, the ‘Pills in Practice’ conference will bring together clinicians and service providers from the UK, Europe and the USA to discuss improvements in contraception and abortion care, and barriers that remain to the development of a service that is genuinely fit for purpose.

For more information about the Pills in Practice conference, including a programe and speakers’ biographies, please see the conference website. Tickets can be purchased here.

This article appears in the Winter 2011 print edition of Abortion Review. Contents also include - Clinical Update: Feticide, by Patricia Lohr; BPAS blog: Anti-abortion protests, by Clare Murphy; News and Medical Digest, July-October 2011. Download this edition for free here. 

USA: The provision of medication abortion in an urban academic internal medicine practice

The study set out to determine whether patient preference is a reason for the limited uptake of medication abortion among internal medicine physicians. From Journal of General Internal Medicine. 

The authors note that mifepristone offers internal medicine doctors the opportunity greatly to expand access to abortion for their patients. Almost 70% of pregnancy terminations, however, still occur in specialised clinics. No studies have examined the preferences of Internal Medicine patients specifically.

The study set out to determine whether patient preference is a reason for the limited uptake of medication abortion among internal medicine physicians.

Women aged 18-45 were recruited from the waiting room in an urban academic internal medicine clinic. A semi-structured questionnaire was used to determine risk of unintended pregnancy and attitudes toward abortion. Support for provision of medication abortion in the internal medicine clinic was assessed with a yes/no question, followed by the open-ended question, “Why do you think this clinic should or should not offer medication abortion?” Subjects were asked whether it was very important, somewhat important, or not important for the internal medicine clinic to provide medication abortion.

Of 102 women who met inclusion criteria, 90 completed the survey, yielding a response rate of 88%. Twenty-two percent were at risk of unintended pregnancy. 46.7% had had at least one lifetime abortion. Among those who would consider having an abortion, 67.7% responded yes to the question, “Do you think this clinic should offer medication abortions?” and 83.9% stated that it was “very important” or “somewhat important” to offer this service. Of women open to having an abortion, 87.1% stated that they would be interested in receiving a medication abortion from their primary care doctor.

The authors concluded that a clinically significant proportion of women in this urban internal medicine clinic were at risk of unintended pregnancy. Among those open to having an abortion, a wide majority would consider receiving it from their internal medicine doctor. The provision of medication abortion by internal medicine physicians has the potential to greatly expand abortion access for women.

Department of Internal Medicine, Beth Israel Medical Ctr., Albert Einstein College of Medicine, New York, NY, USA.

Attitudes and Preferences Toward the Provision of Medication Abortion in an Urban Academic Internal Medicine Practice. Page C, Stumbar S, Gold M. Journal of General Internal Medicine. 2012 Jan 6. [Epub ahead of print]

UK: Telephone follow-up and self-performed urine pregnancy testing after early medical abortion

The authors concluded that a telephone follow-up and a low-sensitivity urine pregnancy test at 2 weeks are effective for detecting ongoing pregnancy, have good follow-up rates and are popular choices for women. From Contraception. 

Telephone follow-up with a self-performed low-sensitivity urine pregnancy (LSUP) test was introduced at the Royal Infirmary of Edinburgh, Scotland, as an alternative to routine ultrasonography for confirming successful abortion at 2 weeks following early medical abortion (<9 weeks' gestation). Women who screened 'positive' at telephone follow-up on the basis of ongoing pregnancy symptoms, scant bleeding or LSUP test result subsequently attended the clinic for a confirmatory ultrasound.

A service evaluation was conducted of the first 8 months of telephone follow-up consisting of a review of the numbers choosing this method of follow-up, the proportion successfully contacted and the efficacy for detecting ongoing pregnancies. In the last 3 months of the study, women were surveyed about their satisfaction with this method of follow-up.

Opting for telephone follow-up were 476 out of 619 women (77%). Four women (1%) attended the clinic before telephone follow-up because of pain or bleeding. A total of 410 (87%) of the remaining 472 women were successfully contacted by telephone. Sixty women (15%) screened 'positive', three of whom had ongoing pregnancies, and one woman falsely screened 'negative'. The sensitivity of the telephone follow-up was 75% [95% confidence interval (CI) 30.1-95.4], and specificity was 86% (95% CI 82.2-89). The negative predictive value was 99.7% (95% CI 98.4-99.9), and positive predictive value was 5% (95% CI 1.7-13.7). All women surveyed (n=75) would recommend telephone follow-up to a friend.

The authors concluded that a telephone follow-up and a LSUP test at 2 weeks are effective for detecting ongoing pregnancy, have good follow-up rates and are popular choices for women.

Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, NHS Lothian, Royal Infirmary of Edinburgh, EH16 5SU, Scotland, UK; Department of Reproductive and Developmental Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, EH16 5SU, Scotland, UK; Chalmers Sexual and Reproductive health Service, Edinburgh, EH3 9ES, Scotland, UK.

Telephone follow-up and self-performed urine pregnancy testing after early medical abortion: a service evaluation. Cameron ST, Glasier A, Dewart H, Johnstone A, Burnside A. Contraception. 2012 Jan 5. [Epub ahead of print]

USA: Patients’ attitudes and experiences related to receiving contraception during abortion care

This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC). From Contraception.

The authors note that high risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC).

Structured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey.

Among abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest.

The authors concluded that many women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.

Guttmacher Institute, Research Division, New York, NY 10038, USA.

Patients’ attitudes and experiences related to receiving contraception during abortion care. Kavanaugh ML, Carlin EE, Jones RK. Contraception. 2011 Dec;84(6):585-93. Epub 2011 May 4.

Copyright © 2011 Elsevier Inc. All rights reserved.

Japan: Effects of parity and gestational age on second-trimester induction-abortion interval

From Contraception. 

The authors note that the true prognostic factors for induced medical abortion are unknown. They sought to investigate the effects of a patient’s obstetric parameters on the induction-abortion interval in second-trimester medical abortion.

The authors studied 216 consecutive women. Pregnancy was terminated with cervical preparation using osmotic dilators followed by 1 mg vaginal gemeprost administered every 3 h for a maximum of five doses in the first 24 h. All variables are expressed in categorical form (parity, gestational age, maternal age and body mass index) and analysed by the Cox proportional hazards model.

Parity ≥3 was associated with a shorter duration of the induction-abortion interval (adjusted hazards ratio 1.96; 95% confidence interval 1.13-3.40). A gestational age ≥16 weeks was associated with a longer duration of the induction-abortion interval (0.71; 0.52-0.98). No significant association was found in maternal age and body mass index.

The authors concluded that in combination with osmotic dilators and gemeprost, gestational age and parity are independent factors that affected the induction to abortion interval of second-trimester medical abortion.

Department of Obstetrics and Gynecology, Kenwakai Otemachi Hospital, Fukuoka 803-0814, Japan; Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan.

Effects of parity and gestational age on second-trimester induction-abortion interval in combination with osmotic dilators and gemeprost. Kai K, Karakida S, Kono M, Sasaki T, Togo K, Tsuno A, Nishida Y, Narahara H. Contraception. 2012 Jan 5. [Epub ahead of print]

Copyright © 2011 Elsevier Inc. All rights reserved.

USA: United States aid policy and induced abortion in sub-Saharan Africa

The study set out to determine whether the Mexico City Policy, a United States government policy that prohibits funding to non-governmental organisations performing or promoting abortion, was associated with the induced abortion rate in sub-Saharan Africa. From Bulletin of the World Health Organization.

Women in 20 African countries who had induced abortions between 1994 and 2008 were identified in Demographic and Health Surveys. A country’s exposure to the Mexico City Policy was considered high (or low) if its per capita assistance from the United States for family planning and reproductive health was above (or below) the median among study countries before the policy’s reinstatement in 2001. Using logistic regression and a difference-in-difference design, the authors estimated the differential change in the odds of having an induced abortion among women in high exposure countries relative to low exposure countries when the policy was reinstated.

The study included 261 116 women aged 15 to 44 years. A comparison of 1994-2000 with 2001-2008 revealed an adjusted odds ratio for induced abortion of 2.55 for high-exposure countries versus low-exposure countries under the policy (95% confidence interval, CI: 1.76-3.71). There was a relative decline in the use of modern contraceptives in the high-exposure countries over the same time period.

The authors concluded that the induced abortion rate in sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced. Reduced financial support for family planning may have led women to substitute abortion for contraception. Regardless of one’s views about abortion, the findings may have important implications for public policies governing abortion.

United States aid policy and induced abortion in sub-Saharan Africa. Bendavid E, Avila P, Miller G. Bulletin of the World Health Organization. 2011 Dec 1;89(12):873-880C. Epub 2011 Sep 27.

India: Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians?

From Contraception. 

The authors note that although legal, access to safe abortion remains limited in India. Given positive experiences of task-shifting from other developing countries, there is a need to explore the feasibility of expanding the manual vacuum aspiration (MVA) provider base to include nurses in India.

A prospective, two-sided equivalence study was undertaken in five facilities of a non-government organisation in Bihar and Jharkhand to explore whether efficacy and safety rates associated with MVA provided by newly trained nurses were equivalent to those provided by physicians. Eight hundred and ninety-seven consenting women with gestation ages of ≤ 10 weeks were recruited.

Nurses were as skilled as physicians in assessing gestation age and completed abortion status, performing MVA and obtaining patient compliance. Overall failure and complication rates were low and equivalent between the two provider types, and both provider types were equally acceptable to women who underwent the procedure (98%).

The authors concluded that findings of the study make a compelling case for amending existing laws to expand the MVA provider base in order to increase access to safe abortion in India.

Population Council, New Delhi, Zone 5A, India Habitat Centre, New Delhi-110003, India.

Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Jejeebhoy SJ, Kalyanwala S, Zavier AJ, Kumar R, Mundle S, Tank J, Acharya R, Jha N. Contraception. 2011 Dec;84(6):615-21. Epub 2011 Sep 28.

Copyright © 2011 Elsevier Inc. All rights reserved.

UK: Figures on selective terminations

Over the past few years, there has been a rise in the number of women terminating one fetus or more but continuing with a pregnancy and bearing at least one other child, the Daily Telegraph reports.

Department of Health figures, released to the Telegraph under Freedom of Information law, show that 59 women aborted at least one fetus while going on to give birth to another baby in 2006. In 2010, the number had risen to 85.

Of the 85 women undergoing selective reductions last year, 51 were reducing a pregnancy from twins to a single fetus, up from 30 four years before. There were also 20 abortions to reduce triplets to twins and nine procedures to take a pregnancy from triplets to a single fetus.

Separate figures from the Human Fertilisation and Embryology Authority show that almost one third of selective abortions carried out in 2009 involved pregnancies that were a result of fertility treatment, the Daily Telegraph reports.

Multiple pregnancies are more dangerous to both mother and fetus and the Department of Health said that about three quarters of the selective reductions were made on medical grounds. The risk of birth defects is about twice as high for multiple pregnancies and the babies are far more likely to be premature. Twins are four to six times more likely to suffer cerebral palsy, and they are also more likely to have impaired sight and heart defects.

Prof Richard Fleming, the scientific director of the Glasgow Centre for Reproductive Medicine, said:

“I would be surprised if multiple pregnancy through fertility treatment was not a significant component to the increase in selective reductions. One of the components within that is the health to the mother and health to the offspring as well – both are compromised by multiple pregnancy. The more complicated multiple pregnancies lie almost exclusively in the IVF domain. It’s a horrible decision to make but a very sensible one.”

Dr Peter Saunders, the chief executive of the Christian Medical Fellowship and a former surgeon, said:

“There is no doubt that the rising use of IVF has contributed to a rise in multiple pregnancies. If prospective parents are not willing to have twins then they should not be implanting more than one embryo at a time. Parental preference should never take precedence over the right to life of the unborn child.”

In 2010 there were 189,000 terminations in England and Wales. Women can apply for an abortion on medical grounds up to the point of birth.

Although selective abortions represent a small proportion of the total figure, they are often viewed as among the most controversial.

In recent years there has been a move to reduce the number of multiple pregnancies because of the risks. In the 1990s the HFEA, which regulated fertility clinics, issued guidance saying that no more than three embryos should be transferred at any one time. A lower limit of two embryos for women aged over 40 was issued in 2001. In recent years the HFEA campaigned to persuade parents and clinics to implant just one embryo at a time and set clinics a limit on the number of multiple pregnancies they could produce.

However despite the risks, many women undergoing fertility treatment remain keen to increase their chance of becoming pregnant by implanting more than one fetus, the Telegraph reports.

“Women are encouraged to have a single embryo implanted and then freeze any others,” said Susan Seenan, from the Fertility Network, a support group. “But if one of the embryos is poor quality or the woman is having treatment on the NHS or paying for it privately, they are likely to want to maximise their chances.”

A spokesman for the Department of Health defended the practice. “Over three quarters, 78 per cent, of the selective terminations were performed under ground E – that there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped,” he said.

“Multiple pregnancies are generally a greater risk to the mother and the babies. The risk is greater for twins than single babies but rises dramatically with three babies or more.”

Abortions to reduce multiple births on the rise. Daily Telegraph, 28 December 2011

China: Mifepristone-induced abortion and vaginal bleeding in subsequent pregnancy

The aim of this study is to explore the effect of first-trimester mifepristone-induced abortion on vaginal bleeding in subsequent pregnancy. From Contraception.

This observational cohort study was conducted during 1998-2001 at antenatal clinics in Beijing, Chengdu, and Shanghai, China. The study enrolled 4,931 women with one previous mifepristone-induced abortion, 4,925 women with no history of induced abortion, and 4,800 women with one previous surgical abortion and followed them through pregnancy and childbirth.

The rates of vaginal bleeding in pregnant women with a history of medical abortion, no abortion, and surgical abortion were 16.5%, 13.9%, and 17.3%, respectively. The women with medical abortion had a higher risk (adjusted relative risk (aRR)=1.17, 95% confidence interval (CI): 1.07, 1.29) of vaginal bleeding compared with those with no abortion but similar risk to prior surgical abortion. When the correlation between medical abortion and vaginal bleeding was examined by period, increased risk was observed only in the early period (<16 gestational weeks) (aRR=1.25, 95% CI: 1.12, 1.39).

The comparison between subgroups of medical abortion and no abortion showed that the observed risks increased particularly in those with abortion at gestational age ≤ 7 weeks (aRR=1.33, 95% CI: 1.18, 1.49), those followed by a postabortion curettage (aRR=1.58, 95% CI: 1.37, 1.84) or complications (aRR=1.99, 95% CI: 1.67, 2.37). There was no difference between women with medical abortion and women with surgical abortion in the occurrence of vaginal bleeding for either period.

The authors concluded that one previous mifepristone-induced abortion increased the risk of vaginal bleeding in early gestation period of subsequent pregnancy compared with no abortion, especially if abortion occurred before 7 weeks of gestation and was followed by a curettage or complications.

Fudan University, Shanghai 200032, China.

Mifepristone-induced abortion and vaginal bleeding in subsequent pregnancy. Liang H, Gao ES, Chen AM, Luo L, Cheng YM, Yuan W. Contraception. 2011 Dec;84(6):609-14. Epub 2011 May 4.

Copyright © 2011 Elsevier Inc. All rights reserved.

Saudi Arabia: Progestogen for treating threatened miscarriage

From Cochrane Database of Systematic Reviews. 

The authors note that miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss.

The study’s objective was to determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage.

The authors searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2011) and bibliographies of all located articles for any additional studies. The selection criteria were randomised or quasi-randomised controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage. At least two authors assessed the trials for inclusion in the review, assessed trial quality and extracted the data. Data were checked for accuracy.

The authors included four studies (421 participants) in the meta-analysis. In three studies all the participants met the inclusion criteria and in the fourth study, they included only the subgroup of participants who met the inclusion criteria in the meta-analysis. There was evidence of a reduction in the rate of spontaneous miscarriage with the use of progestogens compared to placebo or no treatment (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35 to 0.79). There was no increase in the rate of antepartum haemorrhage (RR 0.76; 95% CI 0.30 to 1.94), or pregnancy-induced hypertension (RR 1.00; 95% CI 0.54 to 1.88) for the mother. The rate of congenital abnormalities was no different between the newborns of the mothers who received progestogens and those who did not (RR 0.70; 95% CI 0.10 to 4.82).

The authors concluded that the data from this review suggest that the use of progestogens is effective in the treatment of threatened miscarriage with no evidence of increased rates of pregnancy-induced hypertension or antepartum haemorrhage as harmful effects to the mother, nor increased occurrence of congenital abnormalities on the newborn. However, the analysis was limited by the small number and the poor methodological quality of eligible studies (four studies) and the small number of the participants (421), which limit the power of the meta-analysis and hence of this conclusion.

Chair of Evidence-Based Healthcare and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia, 11451.

Progestogen for treating threatened miscarriage. Wahabi HA, Fayed AA, Esmaeil SA, Al Zeidan RA. Cochrane Database of Systematic Reviews. 2011 Dec 7;12:CD005943.

USA: Women’s decision making regarding choice of second trimester termination method

This study set out to describe how women terminating a pregnancy for fetal or maternal complications decide between surgical (dilation and evacuation [D&E]) and medical abortion. From International Journal of Gynaecology and Obstetrics.

A qualitative study was conducted among women who underwent D&E or medical abortion before 24weeks of gestation for fetal anomalies or pregnancy complications at an academic medical center where both methods are offered. Women were interviewed by phone 1week after the procedure about their counseling experiences and reasons for choosing a particular method. Data were analysed by 3 researchers using a grounded theory approach, and interviews were stopped upon thematic saturation.

Of the 21 women, 13 (62%) chose D&E and 8 (38%) chose medical abortion. Key themes that emerged from the interviews were valuing the ability to choose the method, and the importance of religious beliefs, abortion attitudes, and emotional coping style. Women’s preferences for a method were largely based on their individual emotional coping styles.

The authors concluded that decisions to undergo D&E or medical abortion are highly personal and could affect how women recover after ending a desired pregnancy. Women should be offered counseling about and access to both methods. Understanding these decision processes may help when counseling women faced with these diagnoses and decisions.

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Division of San Francisco General Hospital, San Francisco, USA.

Women’s decision making regarding choice of second trimester termination method for pregnancy complications. Kerns J, Vanjani R, Freedman L, Meckstroth K, Drey EA, Steinauer J. International Journal of Gynaecology and Obstetrics. 2012 Mar;116(3):244-8. Epub 2011 Dec 12.

Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Netherlands: Preconception care and genetic risk: ethical issues

From Journal of Community Genetics.

The authors write that preconception care to address genetic risks in reproduction may be offered either individually to couples with a known or suspected increased risk of having a child with a genetic disorder, or systematically to couples or individuals of reproductive age. The identification of couples at risk of transmitting a (serious) genetic disorder allows those couples to refrain from having children or to adapt their reproductive plans (using prenatal or preimplantation diagnosis, donor gametes, or adoption).

Ethical issues concern the possible objectives of providing these options through preconception genetic counseling or screening, objections to abortion and embryo-selection, concerns about eugenics and medicalisation, and issues arising in the professional-client relationship and/or in the light of the normative framework for population screening.

The authors argue that although enhancing reproductive autonomy rather than prevention should be regarded as the primary aim of preconception care for genetic risks, directive counseling may well be acceptable in exceptional cases, and prevention in the sense of avoiding serious suffering may be an appropriate objective of specific community-based preconception screening programmes. The seemingly unavoidable prospect of comprehensive preconception screening raises further ethical issues.

Department of Health, Ethics & Society, Faculty of Health, Medicine & Life Sciences, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands.

Preconception care and genetic risk: ethical issues. De Wert GM, Dondorp WJ, Knoppers BM. Journal of Community Genetics. 2011 Dec 29. [Epub ahead of print]

Turkey: Strategy for uncontrolled prosthetic tricuspid valve endocarditis

The authors report the case of a 22-year-old woman with a diagnosis of isolated prosthetic TV endocarditis secondary to recurrent abortion. From Heart Surgery Forum. 

Isolated tricuspid valve (TV) endocarditis associated with abortion is a rare entity with a poor prognosis. The authors report the case of a 22-year-old woman with a diagnosis of isolated prosthetic TV endocarditis secondary to recurrent abortion.

The patient had progressed to multiorgan failure and disseminated intravascular coagulation during her clinical course. Because of the high operative risk and uncontrolled infection, the authors performed an unusual surgical approach that has not previously been reported. Resection of infected valvular tissue without replacement of the prosthesis led to a rapid convalescence period and complete cure.

Department of Cardiology, Istanbul Medicine Hospital, Istanbul.

“Removal without replacement” strategy for uncontrolled prosthetic tricuspid valve endocarditis associated with abortion sepsis. Karabulut A, Surgit O, Akgul O, Bakir I. Heart Surgery Forum. 2011 Dec;14(6):E357-9.

USA: Stumbling on status: Abortion, stem cells, and faulty reasoning

From Theoretical Medical Bioethics. 

The author writes that common arguments from the abortion debate have set the stage for the debate on stem cell research. Unfortunately, those arguments demonstrate flawed reasoning-jumping to unfounded conclusions, using value laden language rather than careful argument, and ignoring morally relevant aspects of the situation.

The influence of flawed abortion arguments on the stem cell debate results in failures of moral reasoning and in lack of attention to important morally relevant differences between abortion and human embryonic stem cells. Among those differences are whose interests are at stake and the difference between an embryo in and out of the womb. Stem cell research differs from abortion in morally relevant ways and should be freed from the abortion debate and its flawed reasoning.

Graduate Theological Union, Berkeley, CA, USA.

Stumbling on status: Abortion, stem cells, and faulty reasoning. Lebacqz K. Theoretical Medical Bioethics. 2011 Dec 31. [Epub ahead of print]

UK: The experience of participants in a randomised preference trial of medical versus surgical TOP

From Sociology of Health and Illness. 

The authors note that the termination of pregnancy trial (Newcastle upon Tyne, UK), is the only randomised trial on termination of pregnancy methods incorporating a qualitative element that aimed to understand the experiences of women participating in the trial.

Based on the results of this qualitative work, this article aims to provide insights into two strands of understanding; firstly, women’s experience of participating in research about abortion and secondly, their experience of participating in a randomised preference trial. Semi-structured interviews were conducted of up to 90 minutes with 30 participants recruited at a single hospital site. A total of 20 women from the preference arm and 10 from the random arm were interviewed. The analysis and discussion of the findings use reflexive modernisation as a framework for understanding and interpreting some of the actions of social agents, that is, the participants and trial recruiters in the course of a clinical trial as an expert system.

The authors found that the factors that shape women’s experiences and decisions include trust in the expert system and reflexivity and agency on the part of both participants and trial recruiters.

Institute of Health and Society, Newcastle University Faculty of Health Sciences, University of Southampton Institute of Cellular Medicine, Newcastle University.

‘Let the computer choose?’: the experience of participants in a randomised preference trial of medical versus surgical termination of pregnancy. Lie M, May C, Kelly T, Robson S. Sociology of Health and Illness. 2011 Nov 25. doi: 10.1111/j.1467-9566.2011.01412.x. [Epub ahead of print]

© 2011 The Authors. Sociology of Health & Illness © 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.

UK: Systematic review of induced abortion and women’s mental health published

A major review into the mental health outcomes of induced abortion has been published by the Academy of Medical Royal Colleges (AOMRC) today.

The review concludes that having an abortion does not increase the risk of mental health problems. The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.

The review was commissioned by the AOMRC and carried out by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists.

The review’s Steering Group and the NCCMH carried out a systematic and comprehensive search of the literature and identified 180 potentially relevant studies published between 1990 and 2011. The Steering Group was careful to ensure only the best quality evidence was used, so all studies were subject to multiple quality assessments. In total, 44 papers were included in the review.

On the basis of the best evidence available, the Steering Group concluded that:

• Having an unwanted pregnancy is associated with an increased risk of mental health problems. However, the rates of mental health problems for women with an unwanted pregnancy are the same, whether they have an abortion or give birth.

• The most reliable predictor of post-abortion mental health problems is having a history of mental health problems. In other words, women who have had mental health problems before the abortion are at greater risk of mental health problems after the abortion.

• Some other factors may be associated with increased rates of post-abortion mental health problems, such as a woman having a negative attitude towards abortions in general, being under pressure from her partner to have an abortion, or experiencing other stressful life events.

Dr Roch Cantwell, a consultant perinatal psychiatrist and Chair of the Steering Group, said: “Our review shows that abortion is not associated with an increase in mental health problems. Women who are carrying an unwanted pregnancy should be reassured that current evidence shows they are no more likely to experience mental health problems if they decide to have an abortion than if they decide to give birth.”

Professor Tim Kendall, Director of the NCCMH and a member of the Steering Group, said: “This review has attempted to address the limitations of previous reviews of the relationship between abortion and mental health. We believe that we have used the best quality evidence available, and that this is the most comprehensive and detailed review of the mental health outcomes of induced abortion to date worldwide.”

Professor Sir Neil Douglas, Chairman of the AOMRC, said: “The Academy recognises that this is a complex and controversial area, where there have been many conflicting research findings. We welcome this extremely high-quality review from the NCCMH, and endorse its findings.”

The Steering Group recommends that future practice and research should focus on supporting all women who have an unwanted pregnancy.

A draft version of this review was published in April 2011.

AOMRC press release: Systematic review of induced abortion and women’s mental health published. 9 December 2011

Also read:

Commentary: Abortion is not a mental health problem. By Jennie Bristow. Abortion Review, 9 December 2011

Commentary: Abortion is not a mental health problem

A new review of the evidence finds no causal link between abortion and depression. Now can we move the discussion on? By Jennie Bristow.

A major new review by the Academy of Medical Royal Colleges (AOMRC), published today, concludes that having an abortion does not increase the risk of mental health problems. The best current evidence suggests that it makes no difference to a woman’s mental health whether she chooses to have an abortion or to continue with the pregnancy.

The review was commissioned by the AOMRC and carried out by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists. It was first published in draft form in April this year, and the final publication of this document is a welcome contribution to the ongoing discussion of this issue. In finding no causal relationship between abortion and mental health problems, the report confirms the findings of other authoritative reviews: most notably, the American Psychological Association’s report of 2008.

The key point highlighted by the AOMRC’s review is that mental health outcomes from induced abortion or childbirth are associated with a woman’s mental health before abortion. In other words, if depression follows abortion it is because the woman has a pre-existing mental health condition, not because the abortion itself causes her to be depressed.

Furthermore, it states that mental health outcomes are likely to be the same, whether women with unwanted pregnancies opt for an abortion or birth. The review thus recognises that women seeking abortion must be compared, not with women who are not pregnant or who have wanted pregnancies, but with women in a comparable situation an unwanted pregnancy, which must be carried to term or aborted.

This review provides useful reassurance for women seeking abortion, and those who treat them. But it is also to be hoped that, with this latest review of the evidence about abortion and mental health, the debate about abortion can move beyond this narrow framework. For in reality, women do not have abortions because they are good for their health, or in spite of them being bad for their health. Abortion is a part of the messy reality of life, subject to a whole range of personal, moral, social and relational factors; and the preoccupation with its health effects can skew the debate away from more subtle questions.

The AOMRC’s insistence that the mental health outcomes of abortion and birth are likely to be the same for the woman carrying the pregnancy, depending on any pre-existing mental health conditions she may have, is an implicit recognition of the wider factors at play within the abortion decision. All reproductive outcomes can have some psychological impact, and in today’s society the risk of post-natal depression is widely highlighted as one of the outcomes of birth. Yet women who want to have babies run that risk, because their desire to have a child outweighs their fear of suffering mental health problems. It would be profoundly wrong to counsel a woman with a history of depression that she should have an abortion because it would be better for her mental health.

By the same token, women who have abortions do so because they do not want, or cannot cope with, having a child or another child at this point in their lives. It would be profoundly wrong to counsel this woman that she should have a baby because this would be better for her mental health. That woman is confronted with a choice, which she can only make by weighing up a complex set of personal and emotional factors. Her decision to have an abortion, or a child, is not a health option but a life decision, and one that only she, not doctors, psychiatrists, or counsellors, can make.

Some argue that the way to avoid women suffering potential mental health problems from abortion or childbirth is to ensure that all pregnancies are wanted, or at least intended, through pushing for better use of contraception. Indeed, this is implicit in the AOMRC review’s finding that ‘having an unwanted pregnancy is associated with an increased risk of mental health problems’, and its recommendation that ‘future practice and research should focus on supporting all women who have an unwanted pregnancy’.

But it is worth noting that here again, women’s life circumstances and decision-making are not so clear cut; and an ‘unwanted pregnancy’ is very difficult to define. An unintended pregnancy for example, coming from a failure to use contraception properly, can be a happy surprise, or become a wanted pregnancy; a carefully-planned pregnancy can become unwanted or problematic if a woman’s circumstances change. The pain experienced by women who cannot get pregnant intentionally when they want to have a baby is arguably far greater than that experienced by many women who find themselves needing an abortion, and afterwards experience an overriding sense of relief that they are no longer pregnant.

None of these experiences or emotions can be properly understood through the narrow prism of mental health: they can only be appreciated in the context of women’s lives, the problems and pressures they face, and the available means they have of resolving these things.

As the AOMRC, the APA, and the Royal College of Obstetricans and Gynaecologists (RCOG) recognise, some women who have abortions - as with those who carry their pregnancies to term - suffer from mental health problems that require proper psychiatric care. But this will not be achieved through attempting to provide routine counselling for women considering abortion, when most women do not need it and in environments where specialist mental health skills are always going to be lacking.

Meanwhile, the focus on abortion and mental health has often had the unfortunate consequence of professionalising the understanding of women’s problems and the help and support that they need. It is often felt that doctors need to ‘do more’ to help women make their decisions, or to cope with the consequences of their decisions. But while kindness and caring are important qualities for those working in abortion services, they are not qualities that are limited to health professionals.

Women generally make their decisions about abortion or motherhood with the support of their partners, families and friends. When they make their decision, the primary role of abortion services should be to respect their autonomy to make it.

AOMRC press release: Systematic review of induced abortion and women’s mental health published. 9 December 2011
APA Task Force Finds Single Abortion Not a Threat to Women’s Mental Health; Calls for better-designed future research. American Psychological Association, 12 August 2008

Jennie Bristow is editor of Abortion Review. A version of this article was published in April 2011, based on the draft review.

Also read:

Abortion, mental health, and the limits of science. By Jennie Bristow, Abortion Review, 18 December 2009

Abortion Review topic archive: Mental Health section

UK: A Request for Abortion

The New England Journal of Medicine carries a useful comparison of medical and surgical methods of abortion under 9 weeks’ gestation.

This journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.

The vignette reads:

A 22-year-old student presents to her primary care physician with an unintended pregnancy at 9 weeks of gestation and requests an abortion. She is aware of both medical (drug-induced) and surgical methods of terminating a pregnancy and wants to know which approach would be recommended. She also asks whether either method will affect her future reproductive health. What would you advise?

The article goes on to outline the clinical problem, and offer ‘Strategies and Evidence’ on the following points:

- Medical Abortion
- Surgical Approaches
- Comparison of Medical and Surgical Abortion
- Assessment before Abortion
- Prevention of Infection
- Subsequent Health and Reproductive Risks

The authors go on to highlight some ‘areas of uncertainty’, including that ‘Few randomized trials have compared short- and long-term outcomes of medical and surgical abortion’ - this is partly because ‘the very low rate of serious complications with either type of early abortion means that very large samples would be needed to detect clinically important differences.’ They refer to the guidelines for first-trimester abortion published by the World Health Organization, the National Abortion Federation, the Society of Family Planning, and the Royal College of Obstetricians and Gynaecologists.

The authors’ conclusions and recommendations are as follows:

‘The patient described in the vignette, with a pregnancy at 9 weeks of gestation, should be offered the choice of a medical or surgical abortion. Both are safe with respect to short- and long-term sequelae. Medical abortion is associated with more pain and bleeding and a higher risk of incomplete abortion, whereas the risk of rare complications requiring major surgery is higher after surgical approaches. Antibiotic prophylaxis has well-established benefits in suction curettage and may also be useful in medical abortion, although this is less certain. The patient can be reassured that the best evidence indicates no long-term psychological harm, impairment of future fertility, or increased risk of breast cancer associated with abortion. The insertion of an IUD at the time of the abortion should be recommended to prevent another unintended pregnancy.’

Read the full article for free here:

A Request for Abortion. Allan Templeton, M.D., and David A. Grimes, M.D. New England Journal of Medicine 2011; 365:2198-2204. December 8, 2011

Also read:

Abortion Review topic archive: Early Medical Abortion

UK: Morning-after pill offered free by post

BPAS’ Christmas campaign to encourage women to order emergency contraception in advance gained front-page coverage in the British press, and caught the attention of the Health Secretary, Andrew Lansley.

BPAS is offering emergency contraception free of charge in the post to women who fill in an online form and talk to a nurse over the phone.The British Pregnancy Advisory Service (BPAS) says women could find it difficult to obtain the drug quickly over the holiday period.

The Christmas and New Year period is seen by sexual health charities as a high-risk period for both unwanted pregnancy and sexual infections, BBC News Online reports.

Emergency contraception is effective for the first 72 hours after sex, but is more likely to work the sooner it is taken. It can cause side-effects such as nausea and diarrhoea in some women who take it.

The morning-after pill has been available for several years directly from pharmacies and walk-in-clinics, but BPAS fears that its £25 cost at pharmacies in some parts of the UK, combined with Christmas holiday closures, could discourage women from getting hold of it when needed.

With the BPAS initiative, women will leave their details and a time they can be called in privacy on the webform at www.santacomes.org. A nurse will phone to assess their suitability and to ensure it is not being requested for immediate use. The consultation, which will last about 15 minutes, will include an explanation about how the pill works, when to take it, and what to expect.

The nurse will also be able to answer any questions about more regular forms of contraception and sexual health, as well as provide details of local contraception and sexual health services. The pill will then be despatched with condoms and advice literature to her home address. 

Tracey Forsyth, one of the contraceptive specialist nurses working at BPAS, said:

“We know that women often do not take the morning-after pill after unprotected sex. They may not think their risk of pregnancy is high, and the cost, inconvenience or embarrassment of obtaining it may put them off.

“Having it at home means you are much more likely to take it as soon as you need it. Sometimes women worry that requesting the pill in advance makes it look like you are planning on taking chances. In fact the opposite is true - making sure you have a back-up to help prevent an unwanted pregnancy is making sure nothing is left to chance.”

The initiative was welcomed by sexual health charity FPA, which said it supported anything that might cut the number of unwanted pregnancies.

However, Life, a charity which opposes abortion, said there was no evidence that emergency contraception reduced unplanned pregnancy rates.

A spokesman said: “In fact, if a woman has the morning-after pill at home ‘just in case’ she may be more likely to engage in risky sexual behaviour than she would normally - particularly over the festive period with the associated increase in alcohol consumption.”

Health Secretary Andrew Lansley said of the initiative:

“Emergency contraception is intended to be exactly that - for emergencies not everyday use. Ideally, it would be better for it to be made available in person, which would mean any decisions were taken with the benefit of face-to-face advice.

“Women should be encouraged to use long-acting reversible contraception rather than emergency contraception.”

Ann Furedi, chief executive of BPAS, said she was astonished by Mr Lansley’s comment, given that increasing access to the morning after pill has been a long-standing policy. Furedi said:

“Only a minority of women use the long-acting contraceptives that give the best protection. Most women would benefit from backing up their birth control with emergency contraception to hand. The sooner a woman is able to take it, the more effective it is.

“It makes sense for women to get it in advance of need. You don’t wait until you have a headache to go in search of pain relief; why do politicians think women should wait until they’ve had sex to get emergency contraception? Being responsible is about anticipating when you may be at risk – even when you don’t plan to be.

“We are as committed to helping women avoid the need for abortion as we are to providing first class abortion care. We hope that being able to access the morning-after pill in advance over the phone for free will encourage more women to have one at home, just in case.”

Ann Furedi discussed the BPAS morning-after pill campaign on Radio Four’s Woman’s Hour on 13 December.

Writing on the British Medical Journal blog on 12 December, Marge Berer, founding editor of Reproductive Health Matters, argued:

“A Cochrane review in 2010 found that women who received an advance supply of the morning-after pill had the same chance of becoming pregnant as those who did not have early access to the method. However, these pills do prevent pregnancy when they are used. It seems that many of the women who have unprotected sex and get pregnant without wanting to are not the ones actually obtaining and using the morning-after pill. Perhaps Bpas’ campaign, with the help of all the media who have given it space, will help to change that. According to the Bpas press office, 1,000 women phoned in the first 48 hours. If many more women find out about this method and start to keep a dose or two at home in case they need it, there is a far better chance they can avoid an unwanted pregnancy.”

Morning-after pill offered free by post. BBC News Online, 6 December 2011

bpas launches scheme to allow women access to free emergency hormonal contraception in advance over the phone. BPAS, 6 December 2011

Marge Berer: Jingle pills indeed. BMJ blog, 12 December 2011

Morning After Pill Adverts. Woman’s Hour, BBC Radio Four, 13 December 2011

Women As Moral Agents and the Morning After Pill Debate. By Ann Furedi. Global Herald, 15 December 2011

Also read:

Emergency Contraception: What it does and does not do. By Jennie Bristow. Abortion Review, 9 February 2009

Clinical Update: Emergency contraception. By Patricia Lohr. Abortion Review, 9 February 2009

Abortion Review topic archive: Contraception (EC)

Debate: When it comes to abortion, why wait?

Women who choose to terminate a pregnancy have a moral obligation to do it as early as possible, argues William Saletan.

At the Battle of Ideas festival in London on 29 and 30 October, Will Saletan, a writer for Slate, debated Ann Furedi of the British Pregnancy Advisory Service on the question of: ‘Abortion: how late is too late?’ This was one of three sessions sponsored by BPAS.

An edited transcript of Saletan’s opening comments is published below. A transcript of Ann Furedi’s introduction is published here.

The question that was posed to us is: ‘How late is too late for abortion?’ I am going to violate the rules by not answering that question. What I would prefer to do is bring some facts to bear, put some things on the table, and hope that we can have a conversation and that each of you can think about how late might be too late from your point of view.

The first page of the handout [which Saletan distributed to the audience] has polling data on it. I don’t propose that polls really resolve any issue. But I have put these numbers here in the hope of making you think a little bit, especially if you come from a perspective of believing in women’s rights or personal freedom.

If you look at polling stats and polling data in the US and UK over the past 30 or 40 years, you see massive, progressive shifts in public opinion on questions about the role of women and personal autonomy. So in the UK, you can see in the British Social Attitudes Survey shifts of 24 to 30 points on questions of women staying home when they have kids and whether the wife’s job is to look after the home and family. You see shifts on sexuality, on the rights of lesbian couples; you see shifts on whether certain things are wrong or not. You see huge shifts in relation to the issue of same-sex sex and premarital sex.

When we get to abortion, we don’t see this kind of shift. We see it in the opposite direction, in fact, when the social attitudes survey asked about whether abortion is wrong. So we are seeing people moving on questions of personal autonomy and on questions of women’s rights and women’s roles, but not moving on abortion. Why? I will point out one other thing from the British Social Attitudes Survey: look at the polling on capital punishment. From 1986 to 2009, the percentage of people who said that for some crimes the death penalty is the most appropriate sentence went from 74 to 55. So there was nearly a 20-point drop on this issue.

So perhaps people are seeing the issue of abortion in terms of life, not merely in terms of choice. If you look at data in the US, you’ll see the same patterns on homosexuality and pre-marital sex. Some morals are moving and some are staying the same. One thing I would like to point you towards is the question, ‘Is it all right for a wife to refuse to have children if her husband wants to have children?’. That is a straightforward question of the woman’s rights vis-à-vis the man and vis-à-vis childbearing. And there has been a significant shift in the pro-choice direction on that question, with more people saying women should be able to choose whether to have a family, but not on the issue of abortion. As we can see, the abortion numbers have gone in the other direction.

Again, polls don’t settle questions like this, but they should make us think. And my proposal is that we should realise that there is more to the issue of abortion than feminism or personal autonomy. Abortion is not just an issue of personal rights; it is an issue of one person growing inside another. I am not saying that personhood begins at conception. I do not believe that. What I am saying is that personhood grows and it does so during gestation.

My handout looks at the developments by week of gestation – and this is not information from right-to-life organisations, but from the Royal College of Obstetricians and Gynaecologists and several other sources that I trust. It’s a composite timeline, but what I want you to note is how early on the development of certain capacities begins and how continuous it is. We talk about viability. We talk about what happens at 22 or 24 weeks. But as early as week three, we begin to see differentiation of tissues. You start to see the beginnings of the nervous system as early as week six. You start to see networking within the brain around weeks nine to 12. You start to see movements at weeks 13 to 14. You start to see rudimentary perception at week 16.

And at week 18, you start to see a brain-generated stress response to tissue damage. This is not a question of pain. There has been a lot of debate about fetal pain and there is a lot of legislation going round the US trying to ban abortions at 20 weeks, sometimes earlier, on the basis of the idea of fetal pain.

Pain is a very complicated question. We just don’t have evidence of fetal pain. The Royal College says you can’t have pain until you have the completely wired system. I think the pain debate is a distraction, but what I want you to see is the development of the nervous system. At weeks 22 to 23 you start to see pattern recognition in fetal behaviour. You see habituation, responses to impulses. The fetus is in some sense… I wouldn’t say cognitive, but it is recognising patterns of stimuli and responding accordingly. All of that is happening before the legal abortion limit of 24 weeks. The growth of the rational capacities that signify personhood is a gradual process. It is underway long before the legal limit of abortion rights.

In some of our exchanges online, Ann Furedi has asked: ‘Is there anything qualitatively different at 28 weeks that gives a fetus a morally different status to a fetus at 18 weeks or even eight weeks?’ This timeline is my answer to that question. If you go beyond the 24-week limit, you are starting to see, essentially, viability: the development of lungs and, from weeks 24 to 28, a huge progress in brain construction. There’s another one at about 33 to 37 weeks. So if we are talking about a 28-week fetus, we are already seeing, according to the timeline, ‘spontaneous brain activity of cortical origin’. That, I believe, is a scientific term for ‘thinking’.

Let me skip to the reasons why women are having later abortions. Let’s look at some polling for the US. The number one reason that was given in the US for having a second-trimester abortion is that it took a long time to make arrangements. I think that has to do with the American healthcare system more than anything else. But if you look at reasons for delay that are more prevalent in the second trimester than in the first, the biggest difference is women who say it took a long time for them to decide.

I think we should talk about the reasons why those women take a long time to decide. It isn’t a huge number of women, but still we should talk about the reasons. If you look at data in the UK, it’s a little bit different. A study in England and Wales in 2005 found that the number one reason given by women who had second-trimester abortions as to why it took as long as it did was: ‘I was not sure about having the abortion and it took me a while to make my mind up and ask for one.’ Ann Furedi, in what I think is a commendable act of candour, published a BPAS list of 32 women who had come in for late abortion during a four-week period in 2008 and she published what their stated reasons were and what their circumstances were. It’s worth looking at the reasons given. Several of the women said things like, ‘I had to push it out of my mind, I found the decision hard to make’. This is not the only reason; there are lots of other women who were in totally wrenching circumstances. But some of these cases to me are problematic. If you look at client 18, she said: ‘At first I decided to continue the pregnancy.’ And then she changed her mind based on some circumstance: she thought she couldn’t cope with the child.

I hope we will talk about separating two acts – about separating the choice to have an abortion from the choice as to when you have the abortion. Once you know you are pregnant, my argument is that to delay is a choice, or at least it is something for which you bear some responsibility. And even if you have freedom of choice, you don’t have the right to wait and wait and wait to make a decision. You have a moral obligation to make it as expeditiously as you responsibly can. And that last woman I mentioned, she also said that she was not aware there was a legal time limit on abortion, so she didn’t feel the need to act.

Have we developed a mindset that whatever is legal is moral? Perhaps it is time we talked about the question of what is moral within what is legal, and how long it is moral to wait.

William Saletan is a journalist for Slate and the author of Bearing Right: How Conservatives Won the Abortion War (University of California Press, 2004). The above is an edited transcript of a speech at the Battle of Ideas festival, and was first published on spiked.

Saletan also reflects on the Battle of Ideas debate with Ann Furedi here: Abortion Forever? Slate, 1 December 2011

Also read:

Late abortion debate: When it comes to abortion, why wait? By William Saletan. Abortion Review, 6 December 2011

Late abortion: the new clash in the Choice Wars. By Ann Furedi. Abortion Review, 3 March 2011

Abortion Review topic archive: ‘Late’ abortion

Debate: Abortion: how late is ‘too late’?

Policymakers should butt out of late abortion and trust women to work out what’s in their best interests, argues Ann Furedi.

At the Battle of Ideas festival in London on 29 and 30 October, Ann Furedi of the British Pregnancy Advisory Service debated Will Saletan, a writer for Slate, on the question of: ‘Abortion: how late is too late?’ This was one of three sessions sponsored by BPAS.

An edited transcript of Furedi’s opening comments is published below. A transcript of William Saletan’s introduction is published here.

I think the reason we are having this debate is because there has been a strong argument put forward, particularly in the US, that support for later abortions is a problem. Apparently it is undermining public support for early abortions, and therefore it is becoming a burden and a barrier for the pro-choice movement. I think Will [Saletan] gave an indication of this in his final remarks, where he was kind of making the point that, well, abortion’s okay - just about - but if women are going to do it then they have a responsibility to make sure they do it earlier.

I think this raises some important questions. Because where Will is absolutely right is that public opinion on late abortion is very shaky. It is something that all of us who are involved in abortion care and abortion advocacy find quite difficult, because people look at pictures of the developed fetus and they perceive it as something fundamentally different to a very early embryo. And it is different, in some ways. It looks different; it looks like a baby, and for that reason it can provoke a more visceral response in people than early abortion does. Early abortion is looked upon by many as being more like inducing a period a bit late.

Also, there is a strong understanding in British public opinion that planning parenthood is a good thing and that sometimes contraception fails, and therefore women do need some access to abortion. But because abortion can be done early on, some believe there’s no excuse for women who, as Will indicated, are delaying because they’re having difficulty making up their mind. So I think we can all see that there is a problem when it comes to the debate about late abortion.

What we have to ask ourselves is whether there needs to be any policy intervention or social intervention to change or regulate what is going on at the moment. And I don’t think there does. There is no evidence to suggest that we need to restrict later abortions in any way, by enforcing legal time limits. And I certainly don’t see any reason to think that doctors are abusing the current situation, or indeed that women are abusing the current situation.

It is interesting that on a sentimental level, on an emotional level, women’s attitudes towards their pregnancy changes as the pregnancy progresses. There are many women who say they would have an early abortion but they wouldn’t have a late abortion. The number of women who request late abortions is very small. The number of late abortions that doctors carry out is very small. So consequently, I don’t get any sense that people have a coarsened view or an irrelevant view to the developing life in the womb.

Therefore, what we need to look at is whether there is a moral or a social reason why we should seek to restrict the number of late abortions. Is late abortion having some other impact, other than that on the individual women, which means we should make changes to the present law? I think this is where Will and I profoundly disagree.

I am very pleased that Will passed around a handout, which identifies the developments that take place during gestation, each week. Because for Will, what this does is indicate that there are firm points at which things morally and practically change in the abortion debate. But for me, what this does is actually illustrate my argument that there isn’t any profound point at which you can say there is a difference between one kind of fetus and another.

I accept that abortion stops a beating heart and I accept that abortion ends a potential human life, even in the very earliest weeks of pregnancy. So if we think it’s a morally wrong or morally coarsening thing to do, then I think we should oppose abortion right from the very earliest weeks. If we don’t think that, then we have to ask ourselves, very clearly, who decides when late is too late? Who has the capacity to make that decision, and who has the right to intervene in this area of women’s lives? Because late abortion is a very shaded thing, and it is determined very much by people’s circumstances.

This is a decision that must be taken by the people who are most involved – not by policymakers, not by journalists and not even by people like me, who run services. Women make decisions about abortion in the context of their own lives, and there are some women who would feel that 11 weeks is too late for them, or that 10 weeks is too late for them, because of their personal circumstances. There are other women who, faced with the decision quite late in their pregnancy, will feel that they can no longer bear to carry a child to term.

I would really question why, if there is no objective reason, no objective sudden value change, we need to intervene and create a point at which we apparently have the right to override a woman’s own subjective decision-making process. Because actually, any definition of late abortion is arbitrary and subjective.

The only time at which I am prepared to say that there is a difference in terms of the fetus is at the point of viability at 24 weeks. Because I think then we can say there is something which, in public opinion, represents a visceral stepping over the line. But my only reason for saying this is to do with public policy and what would be publicly acceptable – it is not that I personally think there is a particular difference at 24 weeks.

Does late abortion have a detrimental effect on society? No, I really don’t think it does. There is no evidence that the number of women requesting late abortions is increasing. The figures remain very much the same. However, does the idea that we can override who makes these decisions about late abortion have a detrimental effect on society? Yes, I really believe it does. Because what we’re really saying when we argue that an earlier time limit needs to be imposed is that we don’t trust women’s decisions, and we don’t trust doctor’s decisions.

What struck me about the 32 women who, in the space of a month, came to my organisation to request a late abortion, was that each of them had a compelling reason in their own way. And the idea of compelling those women to continue a pregnancy felt really beyond the pale. Because I think we have to remember that that is the alternative: when we turn around and say to a woman who is requesting an abortion at 20 weeks that she should have requested it earlier, we are still basically saying that we get to decide whether or not to deny her an abortion.

We should trust women to make decisions, because they will look at themselves in the mirror every day for the rest of their lives knowing the decision that they have made. We should trust doctors to make decisions about what they think is safe and acceptable. And as far as possible, we should keep policymakers away from it, and we should try and inform public opinion rather than be swayed by what I think is often ill-informed public opinion.

Ann Furedi is chief executive of BPAS. The above is an edited transcript of a speech at the Battle of Ideas festival, and was first published on spiked. .

Also read:

Late abortion debate: When it comes to abortion, why wait? By William Saletan. Abortion Review, 6 December 2011

Abortion Forever? By William Saletan. Slate, 1 December 2011

Late abortion: the new clash in the Choice Wars. By Ann Furedi. Abortion Review, 3 March 2011

Abortion Review topic archive: ‘Late’ abortion

Inflating the cost of abortion services

In her new blog for Abortion Review, Clare Murphy, BPAS Director of Press and Public Policy, challenges the claim that ‘taxpayers spend £30million a year more on abortion than previously thought’.

Quite frequently, politicians who do not like abortion ask parliamentary questions as to the cost to the public purse of women ending their pregnancies. They seem particularly exercised about what was paid out to the independent sector – primarily comprised of the charities bpas and Marie Stopes - for these services. All of which is fair enough, providing their questions elicit honest answers – rather than figures that are, quite simply, made up. 

Following questioning over the summer by Lord Alton as to what the cost was ‘to the National Health Service of providing abortions in (a) NHS hospitals, and (b) approved independent sector places in 2010’ and in follow-up, whether the government ‘encourages value for money in the purchase of abortions from the independent sector; and whether they collect and make available information on the charges made by the various suppliers of such services’, the Department of Health has come up with a new formulation to answer these queries, as reported in the Daily Telegraph on 22 November. The number of abortions carried out in the independent sector will be multiplied by the NHS’ own average internal tariff for termination of pregnancy.

The problem is that the Department itself accepts that this figure is unlikely to produce an accurate figure, notably because it is ‘aware that contracts with independent sector providers are generally at a lower price than the national tariff’. So while the NHS standard tariff may be £680, our average is more like £425 – likely to be mirrored across the independent sector. This means the DH’s figure of £75m paid to the independent sector in 2010 is likely to be overstated by about 50 per cent.

Perhaps if we operated in a less contentious area, we would be held up by those seeking to ‘open up’ the NHS as an example of how contracting out to the independent sector saves the taxpayer money while delivering high standards of specialist care to the women who need it.  That is certainly not to argue that all NHS caseload should be handed over to independent organisations – far from it. It’s very important the NHS retains a stake in abortion care, not least for the sake of women who cannot be treated in stand-alone units and to ensure future doctors are exposed to this particular area of women’s reproductive healthcare. But it is also important to recognise the role that the independent sector plays in supporting the NHS’ work in abortion services; not least, by delivering high quality services at a lower cost.

Whether independent abortion services were costing the taxpayer £75m or 75p, Lord Alton, the serial questioner on this particular topic, would still keep asking it. But it is unfortunate that at a time of public concern about spending and a new enthusiasm among anti-abortion politicians to deploy the language of American pro-life activists - making liberal reference to the ‘multi-million pound abortion industry/factory/ assembly line’ – such figures pass muster.  Indeed it’s a shame Lord Alton didn’t just call us to find out – we would have happily pointed him in the direction of our page of the Charity Commission website, where all our accounts are published and free for all to see.

Abortion costs £30m higher than previously thought. By Martin Beckford, and Simon Caldwell. Daily Telegraph, 22 November 2011

A Declaration in Support of A Global Campaign for Safe Abortion Access

The following declaration was released on 2 December at the 2011 International Conference on Family Planning in Dakar, Sengal.

The need to integrate safe abortion care within family planning programs and comprehensive sexual and reproductive health and rights has been a recurring theme in the 2011 International Conference on Family Planning.

Despite commitments from ICPD, CEDAW, UN Millennium Development Goals 5 and 5(b) and international women’s conferences, women around the world continue to suffer death and disability due to unsafe abortion. Approximately 22 million unsafe abortions take place globally, contributing to high rates of maternal mortality and morbidity.Each one of these deaths and disabilities is unacceptable and preventable.

Many of these tragic deaths and disabilities can be prevented with the provision of comprehensive, safe abortion care. Abortion care and family planning services are intertwined; they are integral components of comprehensive women’s sexual and reproductive health and rights. These services should be provided to all women irrespective of age, marital status, color, ethnicity, religion, gender and sexual orientation, socio-economic status and where they live and work.

Young women account for almost half of the estimated unsafe abortion-related deaths. Changing demographics will result in a significantly larger proportion of the population being under 25 years old. We need to take immediate action to save young women’s lives so they are able to achieve their true potential and assume rightful leadership in social and economic development.

To respect and fulfill women’s rights and facilitate all women’s access to comprehensive abortion care including family planning services, states are called to decriminalize abortion as per the Beijing Platform for Action and the recent statement to the UN General Assembly by the Special Rapporteur for Health of the UN Human Rights Council.

More political and financial commitment to comprehensive abortion care is required to ensure the fulfilment of goals set by the international community.

Abortion has been systematically neglected in many sexual and reproductive health and rights (SRHR) strategies and programmes. We call for the inclusion of high-quality, accessible and affordable abortion care in all global SRHR programmes and guaranteed access to the full range of safe abortion care for all women.

This declaration was prepared by networks and agencies participating in the 2011 International Conference on Family Planning that are working to advance a global campaign for safe abortion access, including:

- African Network for Medical Abortion (ANMA)

- Asia Safe Abortion Partnership (ASAP)

- Bixby Center for Population, Health and Sustainability at the University of California, Berkeley

- Family Care International (FCI)

- Ghana Health Service, Ministry of Health

- Gynuity

- Ibis Reproductive Health

- International Consortium for Medical Abortion (ICMA)

- International Planned Parenthood Federation (IPPF)

- Ipas

- Latin American Consortium against Unsafe Abortion (CLACAI in Spanish)

- Pathfinder International

- Planned Parenthood Global

- Population Council

- Venture Strategies for Health and Development (VSHD)

- Venture Strategies for Innovation (VSI)

- Women Deliver

A similar declaration was prepared and read by the following partners during the 6th Asia Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR) held in Yogyakarta, Indonesia in October 2011: Asia Safe Abortion Partnership (ASAP), Concept Foundation, Women on Waves, Women’s Global Network for Reproductive Rights (WGNRR) and the International Planned Parenthood Federation East and SE Asia and Oceania Region (IPPF-ESEAOR) and South Asia Region (IPPF-SAR). BPAS was not present at either the Senegal or the Indonesia conferences, otherwise it would gradly have supported these declarations.

Anti-abortion protests

Clare Murphy, Director of Press and Public Policy, discusses the compassion deficit exhibited by protestors outside abortion clinics in Britain. 

When an activist from a local church recorded a day campaigning against abortion outside our Brighton centre earlier this year, they concluded the most challenging part:

‘was the girl visiting Wistons with two of her friends. She just found out she was pregnant – 5 months pregnant – and was returning to the clinic for an abortion. The girl didn’t want to see anything or engage in conversation...Whilst we were able to persuade her friends to look at our information the mother of this unsuspecting child refused to look at anything we had no matter how innocuous. Sometimes it seems in order to go through with killing their unborn children, people must shut down certain normal functions of compassion, logic and reason.’

If ever there were pots and kettles, this writer might well fit the bill – happy to pontificate on their own struggles with a woman considering abortion without a flicker of interest or concern as to how it might
feel to be that young woman, on that day, descended upon by a group of people who felt at liberty to tell her what she was doing was wrong - despite not knowing the first thing about her and her own
very personal circumstances. Indeed there appear to be a burgeoning number of anti-abortion activists who are running short on either compassion or the ability to differentiate logically between a campaign
to alter public opinion on abortion and one that simply seeks to hector and distress individual women as they try to access advice and services.

BPAS is seeing an increase in anti-abortion activity in London and the South-East. The 40 Days for Life protest which ran up to the start of November at one stage saw more than 30 people lined up on the
square in front our central London clinic, staring (but apparently there to ‘help’ ) while their colleagues by our door harangued clients. At least one woman was escorted into the building by a concerned passerby. And clearly unconstrained by the title of their protest, on Day 50 activists were still turning up and declaring that they intended to appear every week. At our South London centre, activists man the gates on a regular basis, and have followed women down the drive telling them ‘you’re killing’, while in Brighton women are regularly encircled, questioned, and graphic material pushed into their hands.

We know women are not china dolls who will automatically crack under the pressure of a graphic leaflet, the sight of 30 people watching them as they enter a clinic, or even being followed down a road and
called a killer. But why should they have to tolerate this as they access healthcare services to which they are legally entitled? We believe if these activists had any sense of compassion, morality or justice, they would take their protest to the court of public opinion – not linger at gates and doorways to target individual women whose personal circumstances and choices they have no interest in or understanding of.

As one woman wrote to us recently after making her way past activists: ‘They are not going to change anyone’s mind, they simply magnify the distress felt by the woman a thousandfold. Maybe this is what they want.’

This article appears in the Winter 2011 print edition of Abortion Review. Download this edition for free here.

Read Clare Murphy’s BPAS blog here.

The Concept of Fetal Life: Politics Drives Perception

Ann Furedi, chief executive of BPAS, reviews Sara Dubow’s book Ourselves Unborn: A History of the Fetus in Modern America. 

This review is published in Conscience magazine, Volume XXXII, No 2, 2011.

Ourselves Unborn: A History of the Fetus in Modern America
Sara Dubow, Oxford University Press, 2011, 320 pp.

Recent discussions about the permissibility of later abortions have raised interesting questions about how we regard the fetus. How much value do we accord to life that has been conceived but not born? Has the way we assess this changed? Does our expanding knowledge of the science of fetal development mean that it should?

For decades, opponents of abortion have called on us to “confront the reality of abortion,” asking us to admit that the embryo is “human and alive” and that abortion “stops a beating heart.” They have accused the prochoice movement of devaluing the fetus, of denying that it is different than any other “blob of tissue” or of likening it to an unwanted growth, a “cancer” or a “parasite.” Their assumption, on the level of rhetoric or conviction, has been that prochoice politics is built on ignorance of what the fetus truly is. Today their challenge to us is this: as modern science tells us more about human development, as 4D scans show us the true face of the fetus, how can we allow its ending through late-term abortion?

Indirectly, implicitly, this book addresses that question.

Ourselves Unborn: A History of the Fetus in Modern America is not an argument about abortion, nor a vehicle for the beliefs of the prochoice movement. Sara Dubow, a historian at Williams College in Massachusetts, has written a detailed and scholarly study of the way value has been attributed to fetal life over the last century. “A fetus in 1870 is not the same as a fetus in 1930, which is not the same as a fetus in 1970, which is not the same as a fetus in 2010,” Dubow says. The change, she explains, is not driven by knowledge about the fetus, but by the emotional and political investment people have in it. Through their approach to the status, development and significance of the fetus, “people— individually and collectively—expressed their assumptions about personhood, family, motherhood and national identity.” How we understand and relate to the fetus is driven by social values and political circumstances far more than by biology or theology.

The book dismisses the idea that the advances in our knowledge about the developing fetus should shape our attitude to fetal status in respect to abortion. It shows that the fascination with fetal feeling, experience and appearance, which seems newly stimulated by today’s scientific discovery, has been a part of the medical, cultural, social and political discourse for more than a century. The form that this discussion takes and the conclusions that are drawn from it have been driven by cultural values and not by accumulated knowledge or new discovery. Throughout modernity, support for women’s choice about the future of her pregnancy was never built on ignorance of fetal life. Instead, it was based on the understanding of the fetus partnered with the concept of what pregnancy, giving birth and raising a child means for a woman.

Today’s commentators assume that, regarding fetal life, our trajectory has been to accumulate evidence that there is little difference between the unborn and the born. Dubow’s first chapter demonstrates how untrue this is. The progression of scientific thinking in relation to the fetus, from Aristotle until the mid-nineteenth century, was not so much a journey to discover how alike babies and fetuses are, bringing us closer to a view that the fetus is deserving of more respect. Rather, she illustrates that the voyage has been one to discover the differences between embryo, fetus and baby. A famous late-fifteenth century drawing by Leonardo da Vinci is generally regarded as the first accurate presentation of the fetus in utero (in “fetal position” ). While feminists have criticized the accuracy of da Vinci’s representation of the uterine context (which appears opened like a Fabergé egg), there can be little criticism of his rendering of the fetus. It is astonishingly similar to the photographs we see today in modern scans and medical textbooks—we are touched by how much it looks like a born “baby.” But in 1487, many would have been surprised by how un-like a man it was. Before then, the fetus was typically illustrated by various kinds of imagined homunculi—little humans—or cherubic infants. (A rich collection of illustrations is included in Karen Newman’s essay, Fetal Positions: Individualism, Science and Visuality, published in 1996 as part of Stanford University Press’s “Writing Science” series.)

Twenty-first century science’s knowledge of the fetus has not exposed the reality of fetal life, nor has it made public support for later abortions untenable. As Dubow reminds us, the Swedish photographer Lennart Nilsson first started to gain recognition for his photographic images of the fetus in the early 1950s.

Nilsson’s iconic series of fetal photographs, which first appeared in the 1965 Life magazine article “The Drama of Life before Birth,” have become the classical reference for feminist discussion of fetal imagery. They employ all manner of deliberate technical presentation and descriptive techniques to evoke “fetal personhood.” And yet, despite the photographer’s intent to dramatize life before birth, just two years later in Britain, and nine years later in the US, abortion was legalized.

In truth, the public has been exposed to, and fascinated by, accurate representations of the fetus for well over a century. Dubow cites the displays of anatomically correct wax models of human embryos, the centerpiece of an 1893 Chicago exposition that attracted crowds of visitors. Forty years later, the fetus was still a public draw, motivating exhibitors to go further to meet the audience for realistic representation. In 1933, some 20 million visitors paid 10 cents each to see a “graduated set of human embryos and fetuses” preserved in formaldehyde “to illustrate the development of an unborn baby from the first month to the eighth.” At this time they were seen as scientific curiosities—educational specimens. Times change, however, and Dubow recounts that, when a similar exhibition was mounted in 1977, the organizer was arrested and charged with the illegal transportation of human remains. Dubow discusses in some detail the changes that had occurred in the intervening decades—how the preserved fetus had turned from a scientific specimen to an emblem of the American family. My point is more straightforward: for more than a century people have known that in later pregnancy fetuses look like babies, and yet they have continued to make legal, moral and public policy decisions related to abortion regardless.

Just as there has been a long-standing interest in what the fetus looks like, so there has been similar interest in what fetuses feel and know. Dubow writes of research at the Samuel S. Fels Research Institute for the Study of Prenatal and Postnatal Environment in the late 1940s, which attempted to address social, psychological and physiological aspects of fetal behavior. She documents studies of “prenatal life” reported in the popular press of the time, such as a magazine article suggesting the new questions being researched: “What happens to a baby before he is born? Is he sometimes uncomfortable? Does he feel motions? Can he hear? Can he think? Is he capable of learning?” Dubow suggests that “prenatal psychology” got a stamp of approval as early as the 1940s, though without any implication of a protected status or fetal life.

The controversies regarding second trimester abortion in the 1970s illustrate most clearly how politics and advocacy are not framed by scientific or medical perception—it is politics that drives perception.

On April 11, 1974, Boston City Hospital physician Kenneth Edelin was indicted for manslaughter following a second trimester abortion. Although the Supreme Court Decision in Roe v. Wade had provided a relatively liberal framework for abortion, this case was complicated by tensions around race, class, ethnicity and concerns about the unchecked authority of doctors and scientists. In a hysterical environment excited by allegations that elective abortions were producing a supply of fetuses for research purposes, some of which were supposedly “kept alive” for experiments, Edelin was accused of causing the death of a fetus. He was said to have deprived a 24-week-old fetus of air after he had carried out an abortion by hysterotomy— by making an incision in the uterus. Edelin denied he had asphyxiated the fetus after delivery, but he was unashamed about his actions as an abortion doctor, which were not intended to result in a live birth. Under cross-examination he confirmed his belief that he owed no duty to the fetus. He was not concerned whether the fetus was live or dead at the start of the procedure since his only concern was for “the mother,” and even if he had thought that the fetus was alive after delivery he would not have called a pediatrician because “this being an abortion before viability,” he thought that an attending pediatrician would have been “number one, contrary to the patient’s wishes, and number two, contrary to good medical practice.”

Edelin was convicted following a sham of a trial, which Dubow describes in detail. The account is fascinating, but even more astonishing were the media reports, which gave unequivocal backing to the abortion doctor. The Boston Globe described Edelin as “a victim of judicial inadequacy that no society should tolerate.” The Washington Post wrote that the Edelin conviction brought “‘disgrace and shame’ to the State of Massachusetts and the entire judicial system … and warned that the impact of the decision ‘on the practice of medicine and on medical research in Boston, and elsewhere, is likely to be enormous.’” The New York Times called the decision “unbelievable” and feared that “it will now become more difficult than ever for women to obtain abortions when they are in the second trimester after conception.”

The case caused the American College of Obstetricians and Gynecologists (ACOG) to issue a statement reaffirming their support for “unhindered access by women to abortion services,” and warned that the profession, “must guard against local jurisdictions or vocal minorities imposing their ethical positions for medical care on family planning and abortion on patients and doctors who do not hold those positions.” The Planned Parenthood Federation of America worried that the decision “will make doctors fearful of performing abortions.” The National Abortion Rights Action League (NARAL) was concerned about the affect on “women with no financial means or alternative options.”

Edelin’s conviction carried with it a maximum sentence of 20 years, but he was sentenced to one year of probation, suspended until the anticipated appeal. In 1976, a unanimous ruling by the Supreme Judicial Court of Massachusetts overturned the conviction.

We can ask—if Edelin were to come to trial today, what chance would there be that the media, ACOG, Planned Parenthood and abortion lobbyists like NARAL would stand together in unequivocal, unapologetic support for a second trimester abortion doctor found guilty of manslaughter?

Sadly, I think we have to concede that many would say—even if convinced of the righteousness of the doctor’s actions—that public support would be unwinnable. Today, late abortion is something even some who call themselves “prochoice” will no longer defend. Their retreat is not because they have learned more about the fetus, but because they have failed to learn what they should about women’s lives.

Dubow’s work shows that, from the late nineteenth century to the early twenty-first century, “the fetus has been a vehicle through which people have wrestled with assumptions about science and religion, anxieties about demography and democracy, beliefs about feminism and motherhood, and ideas about conservativism and liberalism.” This will be as true for the future as it has been for the past. Ourselves Unborn: A History of the Fetus in Modern America tells a story beginning a century ago, when the fetus was framed in a historical context during which, “embryology became a science, obstetrics became a profession, abortion became a crime, birth control became a movement, eugenics became a cause and prenatal care became a policy.” The challenge we face today is to understand the context in which our appreciation of the fetus is currently framed, and our task is to shape that context and not passively accept it.

In 1996, Edelin, who went on to become a chairman of Planned Parenthood, addressed the matter of whether the loss of a fetus in abortion was always a tragedy. He wrote: “Many women choose abortion because of the tragedies in their lives and in the circumstances surrounding their pregnancies. For these women, abortion is not a tragedy; instead it liberates them from tragic circumstances. Women must never be left out of the abortion debate, or the debate about fetal research, medical progress or moral politics.” He was right. Dubow provides the evidence: it is not fetal science that teaches us what we know to be right. Instead, through the years we interpret and understand that science in the context of what appears right from our own and society’s perspective.

Ann Furedi is chief executive of BPAS, and author of Unplanned Pregnancy: Your Choices.

This review is published in Conscience magazine, Volume XXXII, No 2, 2011. Reprinted with kind permission.

UK: New evidence-based guideline on abortion published

Women who have an abortion should not be forced to undergo mandatory counselling before the procedure, the Royal College of Obstetricians and Gynaecologists (RCOG) has said in new guidance.

The RCOG published its revised guidelines on the care of women requesting induced abortion on 23 November 2011.

The clinical guidelines are for all healthcare professionals and aim to ensure that all women considering induced abortion have access to a high quality service based on national standards. The recommendations cover commissioning and organising services, possible side effects and complications, pre-abortion management, abortion procedures and follow up care.

The RCOG’s press release highlights a number of new recommendations, including:

- Services should identify issues which make women particularly vulnerable, for example child protection needs and domestic abuse, and refer them on to appropriate support services in a timely manner.

- Services should provide women with information about the physical symptoms and sequelae that may be experienced after abortion such as pain and bleeding and gastrointestinal symptoms.

- Service providers should inform women about the range of emotional responses that may be experienced during and following an abortion.

- Providers should be aware that women with a past history of mental health problems are at increased risk of further problems after an unintended pregnancy.

- During pre-abortion assessment women should be offered screening for STIs and there should be a system for partner notification and referral to a sexual health service.

- All appropriate methods of contraception should be discussed with women at the initial assessment and a plan agreed for contraception after the abortion.

- Women should have access to counselling and decision-making support, however, women who are certain of their decision should not be subjected to compulsory counselling.

- A 24-hour telephone helpline number should be available for women to use after abortion if they have any concerns.

- Doctors should also discuss ongoing contraception and offer screening for sexually transmitted infections.

Aspects of the new guidance were reported by the Daily Telegraph newspaper and by the news agency PA.

PA reports that ‘a Royal College has explicitly said women who are sure they want an abortion should “not be subjected to compulsory counselling“‘, and that this ‘follows a row in September over the issue of counselling, with Tory backbencher Nadine Dorries and Labour’s Frank Field losing a Commons vote on the issue. They wanted to prevent non-statutory abortion providers such as Marie Stopes and BPAS from offering counselling.’

PA also reports that the new guideline ‘supports the safety of taking pills at home to induce an abortion. This is illegal in the UK and was the subject of a High Court challenge by British Pregnancy Advisory Service (BPAS) earlier this year.’

Ann Furedi,chief executive of BPAS, said the ‘rights and wrongs of abortion are subject to opinion, but clinical risks are a matter of fact’.

She added: ‘We welcome the clear guidance on the offer of counselling. We alsonote the conclusion that home use of misoprostol in early medical abortion is safe andsupported by the evidence but currently not permissible within the law.

‘We trust the necessary steps will be taken soon so that this can be offered to women in Britain,thus allowing us to provide a service in line with international best practice.”

Julie Bentley, chief executive of the Family Planning Association (FPA), said:

‘We believe these are sensible guidelines which will improve women’s experience of abortion services and care. We are pleased to see that they confirm the evidence that abortion is not a direct cause of poor mental health and that there isn’t a link between abortion and breast cancer.

‘We also welcome the recommendation that women can complete the second stage of medical abortion at home if they choose and it’s safe to do so.’

The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7. RCOG, 23 November 2011

RCOG release: Revised guidelines on women seeking induced abortion published. RCOG, 23 November 2011

Women having an abortion ‘should not be forced’ into counselling. Daily Telegraph, 23 November 2011

Call to limit abortion counselling. PA, 23 November 2011

EU: Terminations of pregnancy in the European Union

The authors of this study concluded that the large variation of termination of pregnancy rates between EU member states suggests that rates may be reduced in some countries without restricting women’s access to termination. From BJOG.

The objective was to study the current legislation and trends in terminations of pregnancy in the European Union (EU). Data were collected on legislation and statistics for terminations of pregnancy, from a population of women in reproductive age in the 27 EU member states.

Statistical information until 2008 was compiled from international (n=24) and national sources (n=17). Statistical data were not available for Austria, Cyprus and Luxembourg.

The results found that Ireland, Malta and Poland have restrictive legislation. Luxembourg permits termination of pregnancy on physical and mental health indications; Cyprus, Finland, and the UK further include socio-economic indications. In all other EU member states termination of pregnancy can be performed in early pregnancy on a women’s request.

In general, the rates of termination of pregnancy have declined in recent years. In total, 10.3 terminations were reported per 1000 women aged 15-49 years in the EU in 2008. The rate was 12.3/1000 for countries requiring a legal indication for termination, and 11.0/1000 for countries allowing termination on request. Northern Europe (10.9/1000) and Central and Eastern Europe (10.8/1000) had higher rates than Southern Europe (8.9/1000). Northern Europe, however, had substantially higher rates of termination of pregnancy among teenagers.

The authors concluded that a more consistent and coherent reporting of terminations of pregnancy is needed in the EU. The large variation of termination rates between countries suggests that termination of pregnancy rates may be reduced in some countries without restricting women’s access to termination. Sexual education and provision of access to reliable and affordable contraception are essential to achieve low rates of termination of pregnancy.

Information Department, THL National Institute for Health and Welfare, Helsinki, Finland Nordic School of Public Health, Gothenburg, Sweden Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal Institution of Public Health, University of Heidelberg, Heidelberg, Germany Women’s Clinic, University of Tartu, Tartu, Estonia Faculty of Medicine, University of Lisbon, Lisbon, Portugal Gender, Sexual and Reproductive Health, CESP Centre for Research in Epidemiology and Population Health, Villejuif, France Institution of Epidemiology and Social Medicine, University of Århus, Århus, Denmark Faculty of Medicine and Surgery, Department of Obstetrics and Gynaecology, University of Malta, Msida, Malta Obstetrics and Gynaecology, Ghent University, Ghent, Belgium.

Terminations of pregnancy in the European Union. Gissler M, Fronteira I, Jahn A, Karro H, Moreau C, Oliveira da Silva M, Olsen J, Savona-Ventura C, Temmerman M, Hemminki E; the REPROSTAT group. BJOG. 2011 Nov 30. doi: 10.1111/j.1471-0528.2011.03189.x. [Epub ahead of print]

Pills in Practice: Is abortion and contraception policy meeting women’s needs?

Announcing the BPAS public conference, to be held at the Royal Society of Medicine in central London on Friday 11 May 2012. 

Women in Britain generally receive free and timely access to abortion, contraception and emergency contraception. These are important and welcome developments. But do they go far enough? This one-day public conference brings together clinicians, academics, advocates and service providers from the UK, Europe and the USA to discuss the future of abortion and contraception in Britain. 

Sessions include:

- Home abortions: Do we medicalise too much?

The development of abortion pill means that a greater proportion of abortions takes place in early pregnancy; yet the legal framework surrounding the use of early medical abortion drugs in Britain is at odds with research, clinical guidance, and established best practice in other developed countries. This keynote session examines pioneering international research into the abortion pill, and discusses the political, cultural and legal barriers that can prevent its translation into practice.

• Beverly Winikoff, President, Gynuity Health Projects, USA
• Sam Rowlands LLM MD FRCGP FFSRH, Dorset HealthCare University NHS Foundation Trust and University of Warwick
• Raha Shojai MD MSc, North University Hospital of Marseilles, France
• Kinga Jelinska, project manager, Women on Web, the Netherlands
• Kate Greasley, Dphil candidate in law, New College, Oxford; Lecturer in Law, Hertford College, Oxford

- Contraception: LARCs and their limits

This session examines developments in Long-Acting Reversible Contraceptives (LARCs) such as the implant and the coil. Why aren’t more women using them, and are women’s expectations of ‘fit and forget’ methods appropriately managed? Would greater uptake of these methods have an impact on the number of ‘repeat’ abortions, or would policymakers do better to move away from such instrumental targets?

• James Trussell, Professor of Economics and Public Affairs at Princeton University; visiting professor, the Hull York Medical School
• Dawn Clark, Psychologist, the London Research Centre for Therapeutic Education
• Kaye Wellings, Professor of Sexual and Reproductive Health Research at London School of Hygiene and Tropical Medicine
• Joanne Fletcher, Consultant Nurse Gynaecology, Sheffield

- Contraception: Will the Pill survive a century?

Over 50 years on from the Pill’s introduction into Britain, why has there been no progress in over-the-counter provision? While there have been improvements in access to the morning-after pill, why aren’t we making more of it? How does the broader cultural climate affect developments in contraceptive methods, and women’s attitudes towards them?

• Christian Fiala MD, PhD, Medical Director, Gynmed Clinic for Contraception and Abortion, Vienna and Salzburg, Austria
• Lara Marks, Senior Research Fellow, King’s College London; author, Sexual Chemistry: A history of the contraceptive pill
• Ellie Lee, Reader in Social Policy and Director, Centre for Parenting Culture Studies, University of Kent

- ‘Late’ abortions and fetal anomaly – towards a woman-centred service

What are the particular issues facing women seeking abortion for fetal anomaly, and how could Britain’s ‘late abortion’ service in general be developed and improved? What are the problems and opportunities involved in recruiting and training a new generation of abortion doctors?

• Jane Fisher, Director, Antenatal Results and Choices
• Stephen Robson MB BS MRCOG MD, Professor of Fetal Medicine, Newcastle University
• Helen Statham, Deputy Director and Senior Research Associate, Centre for Family Research, University of Cambridge
• Kate Guthrie, Clinical Director, Hull and East Riding Sexual and Reproductive Healthcare Partnership

- The future of Britain’s abortion service

Ann Furedi, chief executive of BPAS, will summarise the prospects and barriers to developing the kind of abortion service that women need and deserve in the twenty-first century.

TICKET PRICES

Early bird rate (until 30 March 2012)

Clinical/management - £95 - PURCHASE HERE
Nursing/midwifery/academic - £75 - PURCHASE HERE
Unwaged/student - £35 - PURCHASE HERE

Last minute rate (after 30 March 2012)

Clinical/management - £125
Nursing/midwifery/academic - £90
Unwaged/student - £50

For more information, please:

Visit the conference website: www.futureofabortion.org
Email
Phone Jennie Bristow, conference organiser, on:  +44 207 6120206 / +44 7976 414751

Venue: Royal Society of Medicine, 1 Wimpole Street, London W1G 0AE. See here for a map.

Time: 9am-5pm

UK: Medical abortion and the ‘golden rule’ of statutory interpretation

This article reviews the case of BPAS v the Secretary of State for Health [2011] EWHC 235. From Medical Law Review.

The article begins:

At present, approximately 70,000 women a year in the UK seek to terminate a pregnancy by means of an ‘early medical abortion’ (EMA) or, as it is more commonly known, the abortion pill. (1) The relative benefits to women of EMA (available under nine weeks’ gestation) as opposed to the alternative surgical abortion are well known. As well as presenting no anaesthetic risk, EMA is not invasive, less likely to result in complications (like excessive bleeding), and hence also, usually, the least emotionally distressing of the various procedural options. (2) The method involves a two-pill regimen. After initial consultation and testing, the woman is administered the first pill, mifepristone, which acts to block the pregnancy hormone. Between one and three days later, she then returns to receive the second pill, misoprostol, the taking of which brings on a miscarriage. The miscarriage itself is experienced much like a very severe period. Though the level of painfulness naturally varies, it is at the very least an extremely uncomfortable process.

Current practice at the British Pregnancy Advisory Service (BPAS) is that after taking the second pill, (3) the woman is permitted to return home immediately. At many of the clinics, the facilities are not designed to allow for women to remain for the duration of the miscarriage, which can occasionally only occur several hours later, and can last a matter of days. However, since termination symptoms can, and often do, start within minutes of ingesting misoprostol, and since most patients do not live within minutes of the clinic, it can be the case the woman experiences the beginning (and most painful) stage of abortion, and sometimes the miscarriage itself, on her way back from the clinic—in the street, in a car, or while using public transport on her way home. This horrid scenario …

The full text of this article can be purchased here.

Medical abortion and the ‘golden rule’ of statutory interpretation. BPAS v the Secretary of State for Health [2011] EWHC 235. Greasley K. Medical Law Review. 2011 Mar;19(2):314-25. Epub 2011 May 5.

New College, Oxford.

USA: A need to expand our thinking about ‘repeat’ abortions

The authors note that women who have more than one abortion are often the ‘targets’ for social and clinical interventions geared at preventing ‘repeat abortions’. Such an approach ignores the unique circumstances that may surround each abortion. From Contraception. 

The authors qualitatively analysed the history of 10 women who have had more than one abortion who were participating in a larger study of women’s emotional experiences following abortion. Women were recruited following their initial contact with a postabortion support talk line and from a previously completed study.

Overall, women in the sample reported that each abortion was different and some abortions were more emotionally difficult than others, suggesting that the phrase ‘repeat’ can be a misnomer and discounts the unique circumstances surrounding each abortion.

Rather than use the term ‘repeat abortions,’ the authors advocate for the use of the less loaded term ‘multiple abortions,’ in which each abortion is understood as a unique experience.

A need to expand our thinking about “repeat” abortions. Weitz TA, Kimport K. Contraception. 2011 Oct 27. [Epub ahead of print]

USA: ‘Personhood’ amendment fails in Mississippi

A constitutional amendment that would have defined a fertilized egg as a person failed on the ballot in Mississippi on 8 November, the Washington Post reports.

Mississippi would have become the first state to define a fertilized egg as a person, a measure which was aimed at outlawing abortion in the state but, opponents contended, would have led to all kinds of unintended consequences.

In the end, those concerns won out in a strongly anti-abortion state. The amendment trailed 59 percent to 41 percent with more than half of precincts reporting. The Associated Press has said it will fail.

Had the measure passed, many thought it would have led to a new natiowide dialogue on abortion, the Washington Post reports.

The measure earned the support of both Republicans and Democrats in Mississippi — including both of the major parties’ nominees for governor — but some of them hesitated to support it, including outgoing Gov. Haley Barbour (R).

Opponents say that measure could have criminalized birth control, affected in vitro fertilization practices and even forced doctors to decline to provide pregnant cancer patients with chemotherapy for fear of legal repercussions.

‘Personhood’ supporters had tried to pass a similar measure in Colorado in 2008 and 2010, but voters in that state rejected it more than two-to-one both times.

An interesting commentary on the Think Progress blog spells out what the consequences of such a ‘personhood’ amendment could be for women’s reproductive choices.

Anti-abortion ‘personhood’ amendment fails in Mississippi. Washington Post, 11 November 2011

Personhood and Consequences, by Marie Diamond. Think Progress, 7 November 2011

Event: Sex, feminism and late abortion

BPAS sponsored three sessions at the recent London Battle of Ideas festival. Report by Jennie Bristow.

The Battle of Ideas is an annual festival held at the Royal College of Art, attended by an audience of hundreds drawn from members of the public, and with an eclectic range of concurrent debates on issues to do with politics, science, and the arts. This year’s festival ran from 29-30 October.

A session titled ‘Coarse sex and cheap lives’ invited the columnist and broadcaster Anne Atkins, Sue Matthias, editor of FT Weekend Magazine, William Saletan, journalist and author of Bearing Right: how conservatives won the abortion war, and Ann Furedi, chief executive of BPAS, to reflect on the debate about the ‘sexualisation’ of modern society and, within that, whether abortion had become ‘too easy’, leading to a coarsening of cultural values and interpersonal relationships.

One of the main themes to emerge from this debate was the tension between the liberalising trends associated with the 1960s and 1970s, which all the speakers recognised had brought great strides in women’s equality, and features of today’s society that were experienced as more uncomfortable.

Anne Atkins raised the question of whether sexual liberation had benefited women, or whether ultimately it had damaged women and children, who were left abandoned when their partner / father moved on to a new relationship. Her personal and religious belief was that ‘we are created for one person’, and she argued that she did not know a ‘single person who has regretted going for one partner for life’. The positive changes of the Sixties did not ‘necessarily have to lead to promiscuity’, she argued.

Ann Furedi challenged the idea often put forward by critics of those who work in family planning, that ‘we encourage women to have as much sex as possible’; whereas this is not the case. For Furedi, the disturbing aspect of today’s culture is that it has become ‘so focused on sex itself’ that it has been stripped of the idea that sex relates to intimacy. This has its most crude expression in the routine promotion of sexual aids in pharmacies, or sexual health campaigns that promote masturbation as a form of safe, satisfying sex; sexual relations are turned into something technical.

Sue Matthias argued that the sexualisation debate in the policy and media world has generated ‘a lot of heat and not a lot of clarity’. She began by talking about what she was certain of - ‘women’s lives have been transformed for the better by the changes of the 1960s, and women can make choices about their lives’. In relation to abortion, she was certain ‘that women should have the right to choose, that abortion is not chosen lightly, and that late abortion is very rare and used as a desperate last resort’.

About other questions in this discussion, Matthias argued, she was less clear. For example, she does not see young girls walking around dressed as porn stars; however, she does see them dressed in ‘crop tops and Ugg boots’ - in other words, as older women. But does this damage them? We just don’t know, argued Matthias; and rather than ‘veering towards moral panic’, society needs to invest ‘real time and resources into meaningful research’. ‘Evidence is not a substitute for a moral compass, but without it we are in the dark,’ she concluded.

William Saletan focused on the extent to which today’s culture is pushing certain boundaries around what is morally acceptable, and asked the question of whether we can rescue the ‘good stuff’ of the 60s and 70s whilst being aware of some of the problems today. He talked about the need to prioritise prevention - for example, ‘rather than having more marriages, it would be better to have fewer divorces’, and recognising that the abortion pill does not seem to have affected the abortion rate, but (positively) has made it easier for women to have abortions earlier.

In relation to media images and controversial music videos, Saletan proposed that we think about ‘creative filtration’ - creating a ‘safe space’ through such technologies as parent controls, for example, but without imposing censorship. He also discussed the problem of the ‘normalisation’ of sex - ‘in order for something to be special it can’t be ubiquitous’, he said, and ‘the problem with sex being everywhere is that it makes it boring’.

The discussion between the audience and the panel raised a number of issues, from the apparent disconnect between what we see in real life (for example, the clothes that children wear) and what is talked about in media and policy circles, to the idea that people are reacting against the way that the private act of sex now seems to have entered the public sphere. One audience member asked why there was such an obsession with pop videos amongst policymakers and commentators debating these questions; another pointed out that sex has been part of culture for a long time, and wondered whether it was only seen as distasteful because it is now part of popular culture.

It was suggested that the principle, in modern liberal society, of letting people make choices about their sexual lives did not contradict the ability, or the need, to make judgements about the view of sex and sexuality held by today’s society.

In a session titled ‘Abortion: how late is “too late”?’, Ann Furedi and William Saletan went head-to-head about whether there should be limits to the right to choose - and if so, what those limits should be and how they should be imposed. This was a debate between two perspectives within the pro-choice movement, and threw up some more nuanced dilemmas than do more polarised debates between the prochoice/prolife camps.

William Saletan began by citing evidence from polling data showing that there has been a ‘massive shift’ over the past 20 years in positive attitudes towards women’s equality and acceptance of homosexuality and premarital sex; yet attitudes towards abortion have become ‘more negative’. Polls cannot give us the answer to moral questions, argued Saletan, but they do indicate that there is ‘more to the issue than choice’.

Abortion, argued Saletan, is a question of ‘one person growing inside another’; and while he does not belief that personhood begins at conception, he believes that it ‘grows with gestation’. There is no evidence about fetal pain, he argued - pain is ‘a very complicated question’ - but the physical development of the fetus does, in his view, indicate that there is something ‘qualitatively different’ about a fetus at 24 plus weeks from a fetus at a very early gestation.

The biggest reason why women have late abortions, argued Saletan, is ‘the time taken to decide’; and he suggested that we need to ‘separate the choice from the act’. That is, women should have the right to choose, but along with ‘a moral obligation to make the choice earlier’.

Ann Furedi began by indicating that the reason why we are having this debate is because of the ongoing argument amongst supporters of abortion rights that continuing support for late abortion is problematic because it undermines support for early abortion. This, Furedi argued, raises some issues: public opinion on abortion in later gestations is ‘very shaky’, partly because of the widespread understanding that contraception fails and women need access to abortion, but the assumption that ‘this can be done early on’. So, Furedi asked, should there be any policy intervention to change or regulate what is going on?

On a sentimental level, Furedi said, ‘women’s attitude to their pregnancy changes as it progresses’. Abortions in later gestations of pregnancy remain very rare, and ‘there is no reason to think that women have a coarsened view of life in the womb’. In terms of the broader social and ethical issues in this debate, Furedi argued that it is impossible to draw a clear line between a fetus at one gestation and a fetus at another. ‘Abortion stops a beating heart even in the earliest stages. But on that basis, it should be opposed from the start,’ she said.

Another important question regarding time limits for abortion is, ‘who decides?’ There is no sense that late abortion has a detrimental effect on society - it is very rare, and a personal decision made by the woman, ‘who must live with her decision every day of her life’. On that basis, we should trust women and doctors to make the decision, rather than seeking to impose a legal limit.

The argument that abortion destroys a potential baby is, argued Saletan, often used by those who are opposed to abortion per se; by focusing on fetal development, he was attempting to make an argument about ‘actual capabilities’. ‘I don’t think you flick a switch and an embryo becomes a person,’ he said, but a line should be drawn somewhere; otherwise you have the sense that abortion should be allowed up until birth, ‘then what about afterwards?’

For Saletan, the debate was not about whether women should have the right to abortion, but when in pregnancy they should be able to exercise that right. People often say that ‘you can’t be a little bit pro-choice’: in fact, he argued, you can, by saying that women have the choice but it has to have limits. ‘I’m all for trusting women but some will make bad decisions,’ he said.

For Furedi, one of the peculiar aspects of ‘time limits’ on abortion is that it ‘accords women responsibility for a fetus that they don’t have for a born child’. For example, the principle of bodily autonomy means that a woman cannot be compelled to donate a kidney to her child, ‘but she can be compelled to give life to a fetus at 28 weeks’. The key question, she argued, is ‘not when does life begin, but when does it begin to matter?’ What matters is the actuality of personhood; the development of a sense of self.

The process of birth does provide a significant line, not because there is ‘some magical point in the birth canal that transforms the fetus into a person’, but because when the fetus is born, ‘the question of bodily autonomy no longer applies’. As for the question of ‘who decides?’, Furedi noted that Scotland did not have an upper time limit on abortion until 1990, yet there were the same number of late abortions as elsewhere in Britain. This indicates that women and doctors ‘do not need the law’ to frame their moral decision-making in relation to late abortion. Some women do make bad decisions, but in a society that values autonomy and privacy, these decisions need to be theirs to make.

One audience member drew attention to the problems of a morality that seeks to present women having late abortions as ‘moral black holes’, yet considers that these same women should go on and be mothers. She also pointed out that there is a gap between practice and belief: public opinion might have become less supportive of abortion, but women are not having fewer abortions. Another contribution pointed out the contradiction between a policy perspective that, on one hand, makes much of some women’s ambivalence about deciding to have an abortion and counsels them to think about their decision more, and on the other problematises abortions that take place after the first trimester. 

In a lively roundtable discussion on the question, ‘What is feminism for?’, panellists included the poet Anna Percy; Nina Powell, researcher in psychology at the University of Birmingham; Helen Reece, reader in law at the London School of Economics; Cathy Young, contributing editor of Reason magazine and author of Ceasefire! Why women and men must join forces to achieve true equality; and Zoe Williams, Guardian columnist and author of Bring it on, Baby.

The debate in this session focused on the extent to which women had achieved formal equality with men. Nina Powell and Cathy Young suggesting that the old debates around political equality and equal pay had been won, but some panellists and audience members disputed this, pointing in particular to disparities in pay and prestige facing mothers compared to fathers. Young pointed out that today, it is often unclear whether such disparities are the result of inequalities or women making different life decisions, and ‘we can’t pass some law to make women make the same choices as men’.

There was also debate about the persistence of an informal culture of sexism, with Anna Percy focusing on apparently problematic images of women used in advertising. The audience was divided as to whether such images represented a problem at all; and if they did, whether anything could be done about it at a policy level.

Helen Reece argued that, while feminism had generated many powerful and positive intellectual ideas, it was problematic as an ideology because of the extent to which ‘feminism sees violence as a framework for intimate relations’. For example, the trend towards viewing behaviour between male and female colleagues through the prism of ‘harassment’ means that people’s relationships with one another are becoming more finely scrutinised; and rather than leading to a situation where the problem is apparently solved, the problem seems to expand, so ‘there is always more and more harassment, never less and less’.

One of the main discussions between the panel and the audience focused on the question of how feminism is defined, which affects the extent to which people define themselves as feminists and the role that can be ascribed to feminism in society today. ‘You can’t not be a feminist - it’s just being a rational human being,’ stated Zoe Williams in her opening remarks, and Williams took issue with the argument that feminism necessarily involved seeing men as the problem. For Williams, ‘feminism and socialism go together’ - as shown in progressive arguments around the need for childcare.

One contribution from the audience pointed to the theory of patriarchy as the key ideological underpinning of feminism, and asked whether this theory had been shown to be correct or not. Another contribution noted that feminism historically had both a positive and negative aspect: the Women’s Liberation Movement drew attention to some of the problems that were ignored by the political Left, but in focusing on the problem of male behaviour it promoted a divisive view of human relations. 

Over the course of the three sessions, some important conceptual discussions took place about the relationship between men and women, between culture and policy, and between morality and the law. While the practical issues of what a modern society does about such issues as abortion or sexual behaviour remained unanswered, it became clear the questions were at least more nuanced than they often appear.

Also read:

Late abortion: the new clash in the Choice Wars. Philadelphia’s ‘Baby Butcher’ scandal shows exactly why we need a principled defence of abortion - as late as necessary. By Ann Furedi. Abortion Review, 3 March 2011

Coarse sex and cheap lives. By Clare Murphy. The Independent, 22 October 2011

World Health Organization: Medical methods for first trimester abortion

The study set out to compare different medical methods for first trimester abortion. From Cochrane Database of Systematic Reviews. 

The authors note that surgical abortion by vacuum aspiration or dilatation and curettage has been the method of choice for early pregnancy termination since the 1960s. Medical abortion became an alternative method of first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. The most widely researched drugs are prostaglandins (PGs) alone, mifepristone alone, methotrexate alone, mifepristone with prostaglandins and methotrexate with prostaglandins.

The Cochrane Controlled Trials Register, MEDLINE and Popline were systematically searched. Reference lists of retrieved papers were also searched. Experts in WHO/HRP were contacted.

Randomised controlled trials comparing different medical methods for abortion during first trimester (e.g. single drug, combination) were considered. Trials were assessed and included if they had adequate concealment of allocation, randomisation procedure and follow-up. Women, pregnant during the first trimester, undergoing medical abortion were the participants. The outcomes were mortality, failure to achieve complete abortion, surgical evacuation, ongoing pregnancy at follow-up, time until passing of conceptus, blood transfusion, side effects and women’s dissatisfaction with the procedure.

Two reviewers independently selected trials for inclusion from the results of the search strategy described previously.The selection of trials for inclusion in the review was performed independently by two reviewers after employing the search strategy described previously. Trials under consideration were evaluated for appropriateness for inclusion and methodological quality without consideration of their results. Data were processed using Revman software.

Fifty-eight trials were included in the review. The effectiveness outcomes below refer to ‘failure to achieve complete abortion’ with the intended method unless otherwise stated.

1) Combined regimen mifepristone/prostaglandin: Mifepristone 600 mg compared to 200 mg shows similar effectiveness in achieving complete abortion (4 trials, RR 1.07, 95% CI 0.87 to 1.32). Misoprostol administered orally is less effective (more failures) than the vaginal route (RR 3.00, 95% CI 1.44 to 6.24) and may be associated with more frequent side effects such as nausea and diarrhoea. Sublingual and buccal routes were similarly effective compared to the vaginal route, but had higher rates of side effects.

2) Mifepristone alone is less effective when compared to the combined regimen mifepristone/prostaglandin (RR 3.76 95% CI 2.30 to 6.15).

3) Five trials compared prostaglandin alone to the combined regimen (mifepristone/prostaglandin). All but one reported higher effectiveness with the combined regimen. The results of these studies could not be combined but the RR of failure with prostaglandin alone is reportedly between 1.4 to 3.75 with the 95% confidence intervals indicating statistical significance.

4) In one trial comparing gemeprost 0.5 mg with misoprostol 800 mcg, misoprostol was more effective (failure with gemeprost: RR 2.86, 95% CI 1.14 to 7.18).

5) There was no difference in effectiveness with use of a divided dose compared to a single dose of prostaglandin.

6) Combined regimen methotrexate/prostaglandin demonstrates similar rates of failure to complete abortion when comparing intramuscular to oral methotrexate administration (RR 2.04, 95% CI 0.51 to 8.07). Similarly, day 3 vs. day 5 administration of prostaglandin following methotrexate administration showed no significant differences (RR 0.72, 95% CI 0.36 to 1.43). One trial compared the effect of tamoxifen vs. methotrexate and no statistically significant differences were observed in effectiveness between the groups.

The authors concluded that safe and effective medical abortion methods are available. Combined regimens are more effective than single agents. In the combined regimen, the dose of mifepristone can be lowered to 200 mg without significantly decreasing the method effectiveness. Vaginal misoprostol is more effective than oral administration, and has less side effects than sublingual or buccal. Some results are limited by the small numbers of participants on which they are based. Almost all trials were conducted in settings with good access to emergency services, which may limit the generalizability of these results.

World Health Organization, Avenue Via Appia 20, Geneva, Switzerland, CH-1202.

Medical methods for first trimester abortion. Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Cochrane Database of Systematic Reviews. 2011 Nov 9;11:CD002855.

Japan: Confusion and ethical issues surrounding the role of midwives in childbirth and abortion

This qualitative study describes midwives’ experiences in providing care in both pregnancy termination and childbirth in Japan. From Nursing and Health Sciences.

The authors note that midwives working in the general hospital maternity unit assist in both pregnancy termination and childbirth, which is an ethical issue warranting further exploration.

Eleven midwives working in a general hospital were interviewed using a semistructured interview, and responses were coded using thematic analysis.

Two major themes emerged: the experience of midwives involved in childbirth and pregnancy termination (three subthemes: confusion about care of the baby and aborted fetus, inability to cater to different mothers’ needs, and establishing emotional control) and professional awareness and attitude as a midwife (three subthemes: consistency with professional principles, suppression of feelings in relation to aborted fetus, and previous and current professional identities).

The authors found that midwives are isolated in this important social moral issue and its accompanying professional confusion. Suppressing their feelings remains the most common way of dealing with the ambivalence of the roles they fulfill. Improved working conditions and enhanced training on aspects of professional ethics would assist in reducing professional confusion.

Division of Health Science, Kanazawa University, Kanazawa, Japan.

Confusion and ethical issues surrounding the role of Japanese midwives in childbirth and abortion: A qualitative study. Mizuno M. Nursing and Health Sciences. 2011 Nov 17. doi: 10.1111/j.1442-2018.2011.00647.x. [Epub ahead of print]

Canada: Advanced reproductive age and fertility

The study’s objective was to improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging. From Journal of Obstetrics and Gynaecology Canada.

This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility. The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.

Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010. The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report.

The authors made the following recommendations:

1. Women in their 20s and 30s should be counselled about the age-related risk of infertility when other reproductive health issues, such as sexual health or contraception, are addressed as part of their primary well-woman care. Reproductive-age women should be aware that natural fertility and assisted reproductive technology success (except with egg donation) is significantly lower for women in their late 30s and 40s. (II-2A)

2. Because of the decline in fertility and the increased time to conception that occurs after the age of 35, women > 35 years of age should be referred for infertility work-up after 6 months of trying to conceive. (III-B)

3. Ovarian reserve testing may be considered for women ≥ 35 years of age or for women < 35 years of age with risk factors for decreased ovarian reserve, such as a single ovary, previous ovarian surgery, poor response to follicle-stimulating hormone, previous exposure to chemotherapy or radiation, or unexplained infertility. (III-B)

4. Ovarian reserve testing prior to assisted reproductive technology treatment may be used for counselling but has a poor predictive value for non-pregnancy and should be used to exclude women from treatment only if levels are significantly abnormal. (II-2A)

5. Pregnancy rates for controlled ovarian hyperstimulation are low for women > 40 years of age. Women > 40 years should consider IVF if they do not conceive within 1 to 2 cycles of controlled ovarian hyperstimulation. (II-2B)

6. The only effective treatment for ovarian aging is oocyte donation. A woman with decreased ovarian reserve should be offered oocyte donation as an option, as pregnancy rates associated with this treatment are significantly higher than those associated with controlled ovarian hyperstimulation or in vitro fertilization with a woman’s own eggs. (II-2B)

7. Women should be informed that the risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age. Women should be counselled about and offered appropriate prenatal screening once pregnancy is established. (II-2A)

8. Pre-conception counselling regarding the risks of pregnancy with advanced maternal age, promotion of optimal health and weight, and screening for concurrent medical conditions such as hypertension and diabetes should be considered for women > age 40. (III-B)

9. Advanced paternal age appears to be associated with an increased risk of spontaneous abortion and increased frequency of some autosomal dominant conditions, autism spectrum disorders, and schizophrenia. Men > age 40 and their partners should be counselled about these potential risks when they are seeking pregnancy, although the risks remain small. (II-2C).

Advanced reproductive age and fertility. Liu K, Case A. Journal of Obstetrics and Gynaecology Canada. 2011 Nov;33(11):1165-75.

UK: Gloria Steinem talks about abortion, and being angry

Rachel Cooke interviews the veteran feminist for The Observer.

Cooke writes that a pivotal moment in Steinem’s life was when, as a journalist, she went to cover a “speak-out” – in which women would talk about their experiences of abortion:

Steinem had had an abortion herself, aged 22, in London. But she had never spoken of it. She felt a “big click”. The secrecy surrounding abortion suddenly seemed so oddly counterproductive. “It [abortion] is supposed to make us a bad person. But I must say, I never felt that. I used to sit and try and figure out how old the child would be, trying to make myself feel guilty. But I never could! I think the person who said: ‘Honey, if men could get pregnant, abortion would be a sacrament’ was right. Speaking for myself, I knew it was the first time I had taken responsibility for my own life. I wasn’t going to let things happen to me. I was going to direct my life, and therefore it felt positive. But still, I didn’t tell anyone. Because I knew that out there it wasn’t [positive].” A low laugh. “I don’t know about you, but I re-virginised myself several times, too.”

Before she knew it, she was a fully paid-up member of the women’s movement, and she regards it as having saved her life. “For me, this is, and always has been, politics 101,” she says. “The idea that women are supposed to be the means of reproduction. If they – I mean ‘they’ in the larger sense: patriarchy, nationalism, whatever you want to call the mega-structure – didn’t want to control reproduction, we wouldn’t be in the mess we’re in. Remember my age. I didn’t know that I had a choice for a long time. I didn’t want to get married and have children, but I thought it was inevitable, and so, I kept saying: not right now. I kept putting it off. After feminism, I suddenly realised: not everyone has to live the same way. Imagine that!” She never did have children – though she eventually married – and has never regretted it. “I suppose I could analyse it, in the sense that I looked after my mother. But I don’t know that’s really it. That’s too neat. I just never wanted to.” Her sister, on the other hand, had six. “Yeah, she took care of my social obligations. She once said to me: ‘I’m really glad you didn’t get married and have children. If you had, then you would have it all, and I would be jealous.’ I thought that was very honest.” Didn’t she worry about being thought of as cold and unfeminine? She casts me a look. “Who wants to be feminine?”

Steinem never intended to be so visible a figure in the women’s movement – or so she insists. She hated public speaking, and feared conflict. “I know. I’m in the wrong business. But you have no choice, however hard it is. I experience it like this: either I am invisible, or someone I identify with is invisible, and it makes me so angry. It’s so wrong, and then I just can’t resist. I have to do something.” Is she tough? “That’s a good question. I don’t know. Different things hurt you surprisingly. But I always had the feeling, which makes you tough under duress, that I was a survivor.”

But whether she intended it or not, there followed the most remarkable and radical few years – so radical, in fact, that when you look at the footage, you can hardly believe this was America. Steinem’s critics like to point out that, though she has published several books, unlike Betty Friedan’s The Feminine Mystique, or Germaine Greer’s The Female Eunuch, none of them is a set text; her fame, they say, is disproportionate to her influence (and, boy, was she famous: Richard Nixon was recorded furiously ranting about her; his secretary of state, Henry Kissinger, meanwhile, once made a flirty reference to her in a speech). But no one can say that she didn’t get stuff done. She led – in boots and polo neck – march after march. She testified in the Senate on behalf of the Equal Rights Amendment, and co-founded the Women’s Action Alliance and the National Women’s Political Caucus. The first issue of Ms, which was the first periodical ever to be created, owned and operated entirely by women and sold out in a week, contained a feature titled: “We have had abortions”. It was signed by singer Judy Collins, tennis player Billie Jean King, and writers Susan Sontag, Grace Paley, Anais Nin and Nora Ephron (not all of these women had necessarily had abortions; the statement was inspired by those non-Jewish Danes who, during the second world war, wore yellow stars, daring the Nazis to arrest them too). A year later the Roe v Wade judgment was passed down, and abortion was effectively legalised.

“Of course, it has gone back,” she says, now. “In this large country, 85% of counties have no abortion services. The clinics that do exist are still under threat. The so-called ‘right to life groups’ are less likely to firebomb – they got called terrorists, which was awkward – but they still picket and run false clinics and take photographs of women as they go in. One of our two main political parties is anti-abortion, and in some states, they have passed extraordinary legislation so that even those who fall pregnant as a result of incest or rape must hear lectures and see ultrasound pictures. South Dakota tried to pass a law saying that murdering an abortion clinic doctor would be self-defence. It is a struggle, all the time, and it always will be.” ...

Read the full article here:

Gloria Steinem: ‘I think we need to get much angrier’, by Rachel Cooke. The Observer, 13 November 2011

UK: The role of ambulation during medical termination of pregnancy

This was a prospective patient-preference study carried out among 130 women with pregnancies up to 63 days of gestation fulfilling the requirements of the 1967 Abortion Act and undergoing medical termination of pregnancy. From Contraception. 

The authors note that although induced abortion is one of the most commonly performed gynecological procedures in Great Britain and medical termination of pregnancy is being used more frequently, very little is known about the role of ambulation during the procedure. They sought to compare ambulatory and non-ambulatory groups of patients undergoing medical termination in the hospital setting and determine whether ambulation impacted clinical outcomes.

This was a prospective patient-preference study carried out among 130 women with pregnancies up to 63 days of gestation fulfilling the requirements of the 1967 Abortion Act and undergoing medical termination of pregnancy. The objective was to evaluate the effect of ambulation during medical termination of pregnancy. The women were given the choice to be ambulatory or non-ambulatory throughout the process of medical termination of pregnancy. They received 200 mg oral mifepristone and 800 mcg vaginal misoprostol for the termination procedure. Outcomes measured included time taken to pass the products of conception, first feeling of abdominal cramps, estimated blood loss, time to discharge from the hospital, pain scores and need for analgesia.

In both ambulatory and non-ambulatory groups, the mean time taken to pass the products of conception was similar: 230.7 min (118-343.4) and 233.0 min (134.5-331.5) for ambulatory and non-ambulatory patients, respectively. Time to onset of cramps was 75.6 min (29.4-121.8) for ambulatory and 91.7 min (22.2-161.2) for non-ambulatory patients, from administration of misoprostol. Mean estimated blood loss (assessed by weighing the pads as well as blood in bed pan) was less than 100 mL in both groups, and overall, approximately 85% of patients ranked their pain score as 3 or less (on a scale of 0-5). There were no statistically significant differences in the ambulatory versus non-ambulatory groups with regard to clinical outcomes.

The authors concluded that ambulation during medical termination of pregnancy neither appears to influence the amount of bleeding or pain nor hasten the process of medical termination of pregnancy.

Clinical outcomes from a prospective study evaluating the role of ambulation during medical termination of pregnancy. Ojha K, Gillott DJ, Wood P, Valcarcel E, Matah A, Talaulikar VS. Contraception. 2011 Oct 27. [Epub ahead of print]

USA: Intrauterine contraceptive insertion post-abortion

This systematic review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion. From Contraception. 

The authors searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. They used standard abstraction forms to summarize and assess the quality of the evidence.

The search strategy identified a total of 990 articles, of which 19 met the inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion.

Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion.

Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion.

In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group.

The authors concluded that intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion.

Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.

Centers for Disease Control and Prevention, Atlanta, GA, 30341, USA.

Intrauterine contraceptive insertion postabortion: a systematic review. Steenland MW, Tepper NK, Curtis KM, Kapp N. Contraception. 2011 Nov;84(5):447-64. Epub 2011 May 4.

Australia: Intracervical procedures and the risk of subsequent very preterm birth

This was a population-based case-control study, which set out to investigate the relation of prior intracervical procedures with very preterm birth. From Acta Obstetricia et Gynecologica Scandinavica.

The study was conducted in Australia between 2002 and 2004, with a sample of 345 women having a medically indicated and 236 having a spontaneous singleton birth between 20 and 31 weeks of gestation, and 796 women selected randomly from all giving birth at 37 or more weeks of gestation. Interview data were analysed using logistic regression.

The results found that very preterm birth was significantly associated with having any intracervical procedure (AOR = 2.07, 95% CI = 1.6, 2.7), in particular curettage associated with abortion (AOR = 1.80, 95% CI = 1.2, 2.6). Assisted reproductive technologies procedures were significantly associated with medically indicated very preterm birth (AOR = 3.07, 95% CI = 1.8, 5.3), and treatments for precancerous cervical changes with spontaneous very preterm birth: conisation/cone biopsy (AOR = 3.33, 95% CI = 1.8, 6.2), and cauterisation/ablation (AOR = 2.27, 95% CI = 1.4, 3.8). Suction aspiration for abortion, abnormal Pap smear without treatment, and abortion without instrumentation were not associated with very preterm birth.

The authors concluded that intracervical procedures are associated with very preterm birth. Notably, curettage rather than any other procedure associated with abortion appears to be implicated in the risk. The introduction of infection during cervical procedures may be the common link with risks found. Changing clinical practice in the management of abortion and human papillomavirus vaccination may lead to lowering the risks of very preterm birth.

Mother and Child Health Research, La Trobe University, Melbourne, Victoria, Australia. The Royal Women’s Hospital, Parkville, Victoria, Australia School of Public Health & Preventive Medicine, Monash University, Prahran, Victoria, Australia.

Intracervical procedures and the risk of subsequent very preterm birth: a case-control study. Watson LF, Rayner JA, King J, Jolley D, Forster D. Acta Obstetricia Gynecologica Scandinavica. 2011 Nov 15. doi: 10.1111/j.1600-0412.2011.01322.x. [Epub ahead of print]

Germany: Second- and third-trimester termination of pregnancy in women with uterine scar

This study was conducted to evaluate and analyze the efficacy and safety of using gemeprost for second- and third-trimester termination of pregnancy (TOP) in women with uterine scar due to previous cesarean section. From Contraception.

Retrospective analysis of 111 medical TOPs for fetal anomaly or death at 14 to 34 weeks of gestation in women with a history of cesarean section was performed at a German tertiary care center from 2005 to 2009. Abortion was induced via intravaginal application of the prostaglandin analogue gemeprost (1 mg) every 6 h.

One hundred eleven women with one (89.2%) or two (10.8%) previous cesarean sections underwent medical TOP with gemeprost. The median induction-to-expulsion interval was 18 h 24 min (range, 2 h 20 min-168 h 28 min), and in 34 (30.6%) cases, the induction interval was longer than 24 h. The overall incidence of severe complications was 9/111 (8.1%), including one case of silent uterine rupture (with the need for blood transfusion), four cases of atonic and three secondary hemorrhages and one case of peritonitis due to uterine perforation during curettage. Failure of induction (induction-to-expulsion >48 h) occurred in 11 cases (9.9%).

The authors concluded that gemeprost-induced TOP in the second and third trimester in women with uterine scar due to previous cesarean section is effective and has a low complication rate.

Department of Obstetrics and Prenatal Medicine, University of Bonn, 53105 Bonn, Germany.

Second- and third-trimester termination of pregnancy in women with uterine scar - a retrospective analysis of 111 gemeprost-induced terminations of pregnancy after previous cesarean delivery. Domröse CM, Geipel A, Berg C, Lorenzen H, Gembruch U, Willruth A. Contraception. 2011 Nov 11. [Epub ahead of print]

USA: Perceptions of family planning and abortion education

The purpose of this study was to assess medical students’ satisfaction with family planning education at a faith-based medical school. From Contraception.

The authors note that because of religious beliefs against contraception and abortion, family planning education is limited at faith-based institutions. STUDY DESIGN:

A self-administered anonymous questionnaire was designed and distributed to all second- and fourth-year students (n=273) at a faith-based medical school during the 2008-2009 academic year. The questionnaire included items on adequacy of and preference for amount and content of family planning preclinical education and clinical training.

A total of 220 students completed the questionnaire for a response rate of 80.6%. The majority of respondents described the preclinical education as inadequate and preferred increased content on contraception (73.9%), sterilization (68.6%) and abortion (65.2%). The majority of fourth-year students reported appropriate contraceptive clinical training (69.0%), but inadequate sterilization training (54.8%) and abortion training (71.4%) during their third-year OB/GYN clerkship. Approximately half of fourth-year students (51.8%) desired clinical abortion training.

The authors concluded that the majority of students enrolled at a faith-based medical school rated their current family planning education as inadequate and desired additional opportunities.

Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA.

Perceptions of family planning and abortion education at a faith-based medical school. Guiahi M, Maguire K, Ripp ZT, Goodman RW, Kenton K. Contraception. 2011 Nov;84(5):520-4. Epub 2011 Apr 15.

Canada: Abortion counselling and the informed consent dilemma

From Bioethics. 

The author notes that an obstacle to abortion exists in the form of abortion ‘counselling’ that discourages women from terminating their pregnancies. This counselling involves providing information about the procedure that tends to create feelings of guilt, anxiety and strong emotional reactions to the recognizable form of a human fetus.

Instances of such counselling that involve false or misleading information are clearly unethical and do not prompt much philosophical reflection, but the prospect of truthful abortion counselling draws attention to a delicate issue for healthcare professionals seeking to respect patient autonomy. This is the fact that even accurate information about abortion procedures can have intimidating effects on women seeking to terminate a pregnancy.

Consequently, the author argues, a dilemma arises regarding the information that one ought to provide to patients considering an abortion: on the one hand, the mere offering of certain types of information can lead to intimidation; on the other hand, withholding information that some patients would consider relevant to their decision-making is objectionably paternalistic on any standard account of the physician-patient relationship. This is an unsettling conclusion for the possibility of setting fixed professional guidelines regarding the counselling offered to women who are considering abortion. Thus, abortion ought to be viewed as an illuminating example of a procedure for which the process of securing informed consent ought to be highly context-sensitive and responsive to the needs of each individual patient. This result underscores the need for health care professionals to cultivate trusting relationships with patients and to develop finely tuned powers of practical judgment.

University of Victoria in British Columbia, Canada.

Abortion counselling and the informed consent dilemma. Woodcock S. Bioethics. 2011 Nov;25(9):495-504. doi: 10.1111/j.1467-8519.2009.01798.x. Epub 2010 Feb 3.

USA: Abortion follow-up with serum human chorionic gonadotropin testing and in-office assessment

The study was conducted to compare lost to follow-up (LTFU) rates in women having a medical abortion who chose follow-up by in-office ultrasound assessment or serum beta human chorionic gonadotropin (β-hCG) testing. From Contraception. 

This retrospective chart review included 865 women who underwent medical abortion in a free-standing outpatient clinic from September 1, 2007, through September 30, 2010. Patients had a 1-week follow-up evaluation after receiving the medications consisting of in-office ultrasound assessment or serial serum β-hCG testing. Ultrasound assessment was offered throughout the study period, and serum β-hCG testing was offered as of September 1, 2008. Demographic and medical data were reviewed to evaluate LTFU rates based on patient’s chosen method of follow-up. Multivariable logistic regression analysis was performed to evaluate factors that were independently associated with lack of follow-up.

The authors found that LTFU rates increased from 18% to 27% in the first and third years of the study period, respectively (p=.009). LTFU rates with ultrasound and β-hCG testing were 22.9% and 33.7%, respectively (p=.024). In multivariable analysis, follow-up method was not associated with increased LTFU. Increased parity, any previous induced abortion, increased distance from home to clinic site and unemployment were independently associated with increased LTFU.

The authors concluded that although LTFU rates are higher with serum β-hCG testing than in-office ultrasound follow-up in this patient population, the women who choose this method are inherently more likely not to follow-up because of other characteristics that predict a high likelihood of being LTFU. Offering serum β-hCG testing does not decrease the LTFU rate in women having a medical abortion.

University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.

Comparison of medical abortion follow-up with serum human chorionic gonadotropin testing and in-office assessment. Horning EL, Chen BA, Meyn LA, Creinin MD. Contraception. 2011 Nov 4. [Epub ahead of print]

Denmark: Attitudes towards abortion among trainees in obstetrics/gynecology and clinical genetics

This study aimed to provide knowledge about attitudes towards abortion among Danish physicians in training in the specialties of obstetrics/gynecology and clinical genetics. From Acta Obstetricia et Gynecologica Scandinavica. 

The study was a questionnaire survey among trainees in these specialties. Ninety-six responded.

Trainees in clinical genetics were more pro-abortion than those in obstetrics/gynecology (p = 0.04). Of the respondents 30% versus 48% found working with early and late abortions unpleasant. Nearly half agreed to having chosen their specialty despite having to counsel and treat women having abortions. Twenty-one percent agreed that working with late abortion affected their job satisfaction negatively. Those agreeing to the above statements had a tendency towards lower pro-abortion scores than those being indifferent or disagreeing, but the differences were not significant.

The authors concluded that a substantial fraction of physicians in training have negative feelings associated with abortion-related work and require support in handling and coping with these challenges.

Department of Obstetrics and Gynecology, Roskilde University Hospital, Roskilde, Denmark Department of Clinical Genetics, Rigshospitalet University Hospital, Copenhagen, Denmark Department of Public Health, University of Copenhagen, Copenhagen, Denmark.

Attitudes towards abortion among trainees in obstetrics/gynecology and clinical genetics. Ingerslev MD, Diness BR, Norup M. Acta Obstetricia et Gynecologica Scandinavica. 2011 Nov 2. doi: 10.1111/j.1600-0412.2011.01311.x. [Epub ahead of print]

Netherlands: Non-invasive prenatal diagnosis for aneuploidy: toward an integral ethical assessment

From Human Reproduction. 

The authors argue that the great promise of the pending introduction of non-invasive prenatal diagnosis (NIPD) for trisomy 21 (18 and 13) is that it enables one-step, early and safe testing for these abnormalities. The ethical debate so far has been limited to possible drawbacks of routine access to this type of testing: normalisation of testing and abortion and adverse effects on autonomous decision-making.

The authors address the ethical implications of the fact that routine NIPD affects the scope and strategy of current prenatal screening cascades. A decision is needed whether complementary (invasive) testing remains in place in order to avoid a loss of information as compared with current practice. If so, the supposed advantages of NIPD may be less significant than generally assumed. Accumulation of tests challenges informed consent and proportionality. Therefore, an ethical evaluation of the implications of NIPD for the prenatal screening strategy as a whole is needed.

Faculty of Health, Medicine & Life Sciences, Department of Health, Ethics & Society, and GROW, School for Oncology and Developmental Biology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands/Centre for Society and Genomics, Nijmegen, The Netherlands.

Non-invasive prenatal diagnosis for aneuploidy: toward an integral ethical assessment. de Jong A, Dondorp WJ, Frints SG, de Die-Smulders CE, de Wert GM. Human Reproduction. 2011 Nov;26(11):2915-7. Epub 2011 Aug 12.

World population reaches seven billion

The UN’s ‘seven billion people’ estimate has provoked a wave of global commentary, before and after the event. 

Much of the discussion has focused on the thorny question of whether the promotion of family planning programmes with the aim of reducing population growth should be seen as a positive contribution to women’s rights and welfare, particularly in the developing world, or whether there is a danger of using the language of women’s rights to mask an agenda more dubiously associated with ‘population control’. Some have argued that the question of women’s access to contraception and abortion should be de-coupled from broader agendas around population size; others have questioned whether population growth is a problem at all.

An interesting opinion piece in the New York Times attempted to articulate the benefits of global family planning programmes to broader social ends. Nicholas D. Kristof argued that family planning could be ‘a solution to many of the global problems that confront us, from climate change to poverty to civil wars’, and called for more resources to be invested in it.

‘What’s the impact of overpopulation?’ asked Kristof. ‘One is that youth bulges in rapidly growing countries like Afghanistan and Yemen makes them more prone to conflict and terrorism. Booming populations also contribute to global poverty and make it impossible to protect virgin forests or fend off climate change. Some studies have suggested that a simple way to reduce carbon emissions in the year 2100 is to curb population growth today.

‘Moreover, we’ve seen that family planning works. Women in India average 2.6 children, down from 6 in 1950. As recently as 1965, Mexican women averaged more than seven children, but that has now dropped to 2.2.

‘But some countries have escaped this demographic revolution. Women in Afghanistan, Chad, Congo, Somalia, East Timor and Uganda all have six or more children each, the UN says. In rural Africa, I’ve come across women who have never heard of birth control. According to estimates from the Guttmacher Institute, a respected research group, 215 million women want to avoid getting pregnant but have no access to contraception.’

Kristof argued that the result of cuts made to global family planning programmes has been an increase in abortions. He explained:

‘Traditionally, support for birth control was bipartisan. The Roman Catholic hierarchy was opposed, but Republican presidents like Richard Nixon and George H.W. Bush provided strong support. Then family planning became tarnished by overzealous and coercive programs in China and India, and contraception became entangled in America’s abortion wars. Many well-meaning religious conservatives turned against it, and funding lagged. The result was, paradoxically, more abortions. When contraception is unavailable, the likely consequence is not less sex, but more pregnancy.

‘Contraception already prevents 112 million abortions a year, by UN estimates. The United Nations Population Fund is a bête noire for conservatives, but its promotion of contraception means that it may have reduced abortions more than any organization in the world.’

Kristof concluded his article:

‘Finally, a ray of hope: A group of evangelical Christians, led by Richard Cizik of The New Evangelical Partnership for the Common Good, is drafting a broad statement of support for family planning. It emphasizes that family planning reduces abortion and lives lost in childbirth. ‘“Family planning is morally laudable in Christian terms because of its contribution to family well-being, women’s health, and the prevention of abortion,” the draft says.

‘Amen! Contraceptives no more cause sex than umbrellas cause rain.

‘So as we greet the seven-billionth human, let’s try to delay the arrival of the eight billionth. We should all be able to agree on voluntary family planning as a cost-effective strategy to reduce poverty, conflict and environmental damage. If you think family planning is expensive, you haven’t priced babies.’

However Marge Berer, editor of the journal Reproductive Health Matters, challenged Kristof’s two central assumptions.

‘The first is the erroneous assertion that family planning is a solution to “many of the global problems that confront us, from climate change to poverty to civil wars”,’ Berer said. ‘On its own, family planning is not a solution to either climate change or poverty, though its greater use by those who have an unmet need for “family planning” would be beneficial and contribute in both instances. I would be interested to learn whether there is any evidence whatsoever that family planning use reduces civil wars, however; I doubt such evidence exists or could even be produced. Similarly, I doubt there is evidence that “youth bulges” make countries more prone to conflict or terrorism.’

Berer also challenged the idea that idea that pro-choice individuals should give ‘support, let alone praise, for anyone who supports the use of contraception but at the same time condemns women’s need for safe, legal, induced abortion’. Those who promote contraception at the expense of abortion, she argued, ‘are not our friends and they are not the friends of women anywhere in the world. Abortion is an essential part of family planning, always has been and always will be, whenever contraception fails or people fail to use it, no matter whether contraceptive prevalence is high or not.’

Berer continued:

‘There is no need to tout contraception as a cure-all or a panacea for all the world’s ills. It is valuable enough in itself that there should be no need to pretend it is more than it is.’

The Birth Control Solution. By Nicholas D. Kristof. New York Times, 2 November 2011

World’s 7 billionth baby causes journalistic storm, by Marge Berer. The Berer Blog, 9 November 2011

Also read:

Abortion Review topic archive: Population debate

USA: Catholics for Choice submits testimony to Congress

CfC President Jon O’Brien testified that refusal clauses within the new health law threaten ‘the conscience rights of every patient seeking family planning and of every provider who wishes to provide comprehensive care to their patients’. 

On 2 November, Catholics for Choice president Jon O’Brien was invited to testify before the US House of Representatives Committee on Energy and Commerce Subcommittee on Health, to address the question, ‘Do New Health Law Mandates Threaten Conscience Rights and Access to Care?’

The hearing was called by Rep. Joseph Pitts (R-PA), chairman of the Subcommittee. Rep. Pitts was the sponsor of HR 358, a recently passed bill that gave unprecedented exemption rights to hospitals, allowing them to refuse to provide abortion care, even when necessary to save a pregnant woman’s life.

In his testimony, Jon O’Brien argued that Catholics support the recently enacted healthcare reforms and the recommendation that contraception be included in fully covered benefits for all American employees. He noted:

‘I firmly believe the requirements under the Affordable Care Act, and the slate of regulations being created to implement it, infringe on no one’s conscience, demand no one change her or his religious beliefs, discriminate against no man or woman, put no additional economic burden on the poor, interfere with no one’s medical decisions, compromise no one’s health—that is, if you consider the law without refusal clauses.’

However, he argued that the refusal clauses in the new legislation and proposed expansions concerning implementation guidelines mitigate the benefits of the reforms. ‘When burdened by refusal clauses, the new health law absolutely threatens the conscience rights of every patient seeking family planning and of every provider who wishes to provide comprehensive care to their patients.’

Even among Catholics, he said, these restrictions are unpopular: 63% of Catholic voters polled last year believe insurance should cover the costs of contraception; 65% think that if a Catholic hospital receives any government funding, it should not be allowed to use “religious beliefs” as a reason refuse to provide procedures or medications. This isn’t surprising when 98 percent of sexually active American Catholic women have used a method of birth control banned by the Vatican.

Noting that the vast majority of Catholics reject the dictates of the US bishops on matters related to reproductive healthcare, O’Brien laid the blame for the attempts to restrict access to family planning at the doorstep of the United States Conference of Catholic Bishops (USCCB) and their lobbying efforts. ‘Having failed to convince Catholics in the pews, the USCCB and other conservative Catholic organizations are attempting to impose their personal beliefs on all people. They claim to represent all Catholics when, in truth, theirs is the minority view,’ O’Brien argued.

During the hearing Jon O’Brien affirmed that if refusal clauses are enacted, such restrictions would ‘go far beyond their intent of protecting conscience rights for all by eliminating access to essential healthcare for many, if not most patients, especially in the area of reproductive healthcare services’, making it ‘harder for many working Americans to get the healthcare they need at a cost they can afford.’

‘Protecting individual conscience and ensuring access to affordable, quality care is not just an ideal, it is a basic tenet of our society and it is the right thing to do,’ O’Brien concluded.

A copy of Jon O’Brien’s written testimony can be downloaded here:

Written Testimony for the Hearing Record on ‘Do New Health Law Mandates Threaten Conscience Rights and Access to Care?, submitted by Jon O’Brien, President of Catholics for Choice. 2 November 2011

Catholics for Choice Urges Congress to Protect Every Person’s Conscience. Press release, 2 November 2011

Northern Ireland: 150-year-old law still lacks clarification

A thought-provoking article in the Belfast Telegraph reviews the consequences of the ‘messy’ abortion law for what we know about the extent of abortion in Northern Ireland. 

McCann writes:

‘The law on abortion in Northern Ireland is 150 years old this month and it’s never been in more of a mess. Every year, abortions are carried out in the north which are, on the face of it, illegal, while women travel to Britain for abortions which could legally be carried out here.

‘No one can say for certain what proportion of the abortions carried out here are unlawful. The Department of Health refuses to record the reasons for abortions in the north and the ‘pro-life’ lobby wants to keep it that way.’

McCann reviews the state of Northern Ireland’s law, where the 1861 Offences Against the Person Act made abortion a criminal offence. ‘The operation of the Act was developed over the years, most significantly in the 1939 Bourne case, in which a doctor was prosecuted for arranging an abortion for a 14-year-old pregnant as a result of multiple rape,’ he explains.

‘Dr Bourne was acquitted on the grounds that a provision introduced in 1925 exempting abortions carried out to save the life of the mother covered situations where continuing the pregnancy might “make the woman a physical or mental wreck”.

‘This interpretation governed abortion practice across the UK until superseded by the 1967 Act as far as England, Scotland and Wales were concerned. The 1967 Act wasn’t extended to the north. As a result, the Bourne judgment remained the last word here.’

A number of causes in the High Court of Northern Ireland during the 1990s, argues McCann, ‘spelled out what the law now said’: that abortion was legal in cases where continuing the pregnancy would have profound implications for a woman’s physical or mental health. McCann writes:

‘In each of these cases, the courts ruled that an abortion here would be legal. But in each, the woman or girl had to travel to England.

‘This suggests that abortion is legal in the north in far more cases than is generally admitted and that a considerable number of the women who travel to England, or elsewhere, for terminations would have a legal right to terminations here.’

A decade ago, explains McCann, ‘the Family Planning Association went to the courts asking for clarification’. Draft guidelines were eventually issued by the Department of Health for consultation in 2007 and 2008, and ‘final’ guidance published in 2009; but these were withdrawn after a High Court challenge by the Society for the Protection of the Unborn Child challenged these guidelines in the High Court. ‘Re-revised guidelines’ were issued for consultation in July, with the final date for responses was set as October 2010. The guidelines have still not yet been published.

McCann concludes his article thus:

‘About 80 and 100 abortions are carried out in the north every year. Anecdotal evidence and what we might call “the word in the ward” strongly suggest that a large percentage of these are for reasons of foetal abnormality. These, unlike abortions carried out because of the implications of the pregnancy for the women, are illegal.

‘Thus, it is likely the case that most of the abortions carried out in the north are illegal, while most of the abortions which take place elsewhere would be legal if carried out here.

‘We cannot put figures to any of this because the Department of Health doesn’t record, or collate, the reasons for abortions carried out in the north.

‘On July 1, Jim Allister asked Edwin Poots when he would review this practice.

‘Poots replied that this would have to await publication of the aforementioned guidelines.

‘They don’t know - and they don’t want to know - because they know they can’t handle the truth.’

Executive refuses to face the truth about abortion. By Eamonn McCann. Belfast Telegraph, 2 November 2011

South Africa: Health care providers’ perspectives on public second trimester abortion services

This study aimed to understand better what doctors, nurses and hospital managers involved in second trimester abortion care thought about these services and how they could be improved. From Journal of Biosocial Sciences. 

The authors note that around 25% of abortions in South Africa are performed in the second trimester. In this study nineteen in-depth interviews with abortion-related service providers and managers in the Western Cape Province, South Africa, were undertaken. Data were analysed using a thematic analysis approach.

Participants expressed resistance to the dilation and evacuation (D&E) procedure, as this required more active provider involvement. Medical abortion was preferred as it required less provider involvement in the abortion process. A shortage of providers willing to perform D&E resulted in most public sector services being outsourced to private sector doctors.

Respondents noted an increased demand for services and a concomitant lack of infrastructure, physical space and personnel to respond to these demands, sometimes resulting in fragmented or poor quality care. At medical induction sites, most thought introducing the combined mifepristone-misoprostol regimen would improve service capacity, although they were concerned about cost.

Improving contraceptive services was also seen as a much-needed intervention to improve care and prevent abortion. Ongoing training, including values clarification, as well as emotional support and team-building for providers are needed to ensure sustainable, high-quality second trimester abortion services.

Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.

The challenges of offering public second trimester abortion services in South Africa: Health care providers’ perspectives. Harries J, Lince N, Constant D, Hargey A, Grossman D. Journal of Biosocial Sciences. 2011 Nov 17:1-12. [Epub ahead of print]

USA:Attitudes towards prenatal testing among parents of children with intellectual disabilities

The objective of this study was to determine how parents of children with intellectual disabilities view prenatal testing and pregnancy termination for their child’s condition. From Prenatal Diagnosis. 

The authors interviewed 201 English-speaking or Spanish-speaking caregivers of children aged 2 to 10 years. Primary outcomes were being disinclined to undergo prenatal testing or pregnancy termination for the child’s condition in a future pregnancy.

While only 33% of the sample indicated they would not have prenatal testing, 75% were disinclined to terminate their pregnancy if their fetus was affected. In multivariable logistic regression analysis, Asians were significantly less likely than White participants to say they would forego prenatal testing (adjusted odds ratio (aOR) = 0.08, 95% confidence interval (CI) = 0.01-0.86, p = 0.037), while Latinos had lower odds of being disinclined to terminate (aOR = 0.27, 95% CI = 0.07-0.99, p = 0.048).

Participants who felt that abortion for their child’s condition should not be available were more likely to say they would forego prenatal testing (aOR = 5.10, 95% CI = 2.09-12.43, p < 0.001) and, not surprisingly, they were also at higher odds of being disinclined to terminate pregnancy for this condition (aOR = 13.63, 95% = CI 4.19-44.34, p < 0.001). Greater life satisfaction also was associated with being disinclined to terminate pregnancy (aOR = 3.40, 95% CI = 1.34-8.61, p = 0.010).

The authors concluded that that although many parents of children with intellectual disabilities believe they would desire information regarding their fetus in a future pregnancy, most feel they would not opt to terminate their pregnancy. As new tests for intellectual disabilities become available, determining what would be most useful to prospective parents should become a high priority.

Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, School of Medicine, University of California, San Francisco, CA, USA.

Attitudes toward prenatal testing and pregnancy termination among a diverse population of parents of children with intellectual disabilities. Kuppermann M, Nakagawa S, Cohen SR, Dominguez-Pareto I, Shaffer BL, Holloway SD. Prenatal Diagnosis. 2011 Oct 26. doi: 10.1002/pd.2880. [Epub ahead of print]

Italy: Maternal risk factors for preterm birth

The aim of this study was to identify maternal risk factors for spontaneous preterm birth (PTB) compared to delivery at term, in order to recognise high risk women and to provide a global overview of the Italian situation. From European Journal of Obstetrics, Gynecology, and Reproductive Biology. 

A multicentre, observational and retrospective, cross-sectional study was designed. The study population comprised 7634 women recruited in 9 different University Maternity Hospitals in Italy.

The main criteria for inclusion were: women having had vaginal preterm or term spontaneous delivery in each participating centre during the study period. The records related to deliveries occurring between April and December 2008. A multivariable logistic regression was employed to identify independent predictors of spontaneous preterm birth. Odds ratios (ORs) and 95% confidence intervals (95% CI) were reported with two-tailed probability (p) values. Statistical calculations were carried out using SAS version 9.1. A two-tailed p-value of 0.05 was used to define statistical significant results.

A significant increased risk of PTB was found in women with BMI>25 (OR=1.662; 95% CI=1.033-2.676; p-value=0.0365) and in women employed in heavy work (OR=1.947; 95% CI=1.182-3.207; p-value=0.0089). Moreover there was a significant association between PTB and previous reproductive history. In fact a history of previous abortion (OR=1.954; 95% CI=1.162-3.285; p-value=0.0116) or previous caesarean section (OR=2.904; 95% CI=1.066-7.910; p-value=0.0371) was positively correlated to the increased risk of PTB and an important statistically significant association was calculated between PTB and previous pre-term delivery (OR=3.412; 95% CI=1.342-8.676; p-value=0.0099). All the other covariates examined as potential risk factors for PTB were not found to be statistically significantly related (p-value>0.05).

The authors concluded that the present study, applied to a substantial sample of Italian population, demonstrates that there are peculiar risk factors for spontaneous PTB in the Italian population examined. It shows an association between preterm delivery and certain maternal factors as: BMI, employment, previous abortions, previous PTBs and previous caesarean section.

Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy.

Maternal risk factors for preterm birth: a country-based population analysis. Di Renzo GC, Giardina I, Rosati A, Clerici G, Torricelli M, Petraglia F; the Italian Preterm Network Study Group. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2011 Oct 27. [Epub ahead of print]

Understanding abortion statistics

A bpas briefing produced by Abortion Review. Last updated on 24 May 2011.

Download the full briefing as a .pdf here: Understanding Abortion Statistics, or follow the links below to read it online.

The 2010 abortion statistics for England and Wales are published by the Department of Health and available here.

Read commentary on the key trends from the 2010 statistics here.

Contents

1) Introduction: About abortion statistics
Where do abortion statistics come from? What the statistics can tell us; What the statistics cannot tell us; Which statistics to treat with particular caution.

2) Number of abortions
How many abortions are there? What is the abortion rate? What is the birth rate? How many women come to Britain from overseas to have an abortion? How many women have ‘repeat’ abortions? What factors affect the abortion rate? Relevant commentary.

3) Grounds for abortion
How are the legal grounds applied in practice? How common is termination of pregnancy for fetal anomaly? Relevant commentary.

4) Age, marital status, previous children, and ethnicity
How does abortion relate to age? Abortion and fertility rates; Marital status, previous children, and ethnicity; Relevant commentary.

5) Gestation, method and complication rates
‘Early’ abortion; Later abortion; Methods of abortion; Which method is best? How safe is abortion? Relevant commentary.

6) Provision, funding and geographical location
Who provides abortions? What are the geographical variations in abortion provision? How is abortion regulated? Relevant commentary.

7) Further resources

Coarse sex and cheap lives

Commentary by Clare Murphy, head of public policy at BPAS, in the Independent.

Women in the UK wait longer than anyone else to start a family, sometimes making use of abortion as a backup to contraception to control fertility on the way.  Is this reflective of a culture of unadulterated self-centredness, or a society, which, far from showing disregard for human life, takes the decision to have a child very seriously indeed?

On average British women are now pushing 30 before they have their first child, making the age of first-time motherhood among the highest in the world. We are older than new Japanese mums, more mature than the French. The consequence is this: British women now spend the time when they are most fertile and most likely to be having regular sex not wanting to be pregnant. Given that contraception fails – and that sometimes we fail to use it properly – this ambition isn’t always met.  What’s surprising is not that Britain’s abortion rate is particularly high – but that it is not higher.

The arguments as to why British women are delaying motherhood are well established though presented in different ways – the woman described by one journalist as cash-hungry and career-driven will be viewed by another as seeking a degree of personal fulfilment and financial security; the flighty commitment-phobe may equally be portrayed as the woman who wants to ensure she’s found a soul mate. But even simple self-centredness can be squared with responsibility if it comes to acknowledging that childbearing would be better postponed for a time in life when there is less preoccupation with oneself. However you construe it, motherhood is not something you enter into on a whim – and child-rearing has perhaps never been subject to such intense discussion.

Most people in Britain accept abortion as a back-up to failed contraception, preferably in the context of a moderately stable relationship, but there is more discomfort when unwanted pregnancy is the consequence of a Hogarthian night on the town in which contraception was neither on the mind or in the pocket. It is these circumstances which the former champions of the sexual revolution may have in mind when they lament that girls have perhaps not grown up to handle their new freedoms wisely.  There is a sense that more straightforward access to abortion, and in particular the advent of the abortion pill, with which a pregnancy can be ended without any surgical intervention, has given us all a much more lax attitude towards casual relationships and unprotected sex because the consequences can be so swiftly eliminated with a handful of medication.

In reality, more than half of the women seen by bpas report using contraception when they fell pregnant. Most arrive with supportive partners.  Typically, women are beside themselves to find they have an unplanned, unwanted pregnancy.  And whether a woman is pregnant through an episode of casual sex or in the context of an intimate and loving relationship, neither sets out to end up in an abortion clinic – however kind the staff, however swift the service, however acceptable the forms of treatment. Indeed it’s worth noting that as the abortion pill has become more widely available in recent years – now used by more than half of women ending pregnancies in the first trimester – the abortion rate has remained stable.

Abortion has long existed on two levels – the political, philosophical plane where we can debate morality and equality, and the practical needs of women who do not see themselves as making a political statement when they cross the threshold of a clinic but who come in the hope of resolving an intensely personal problem. This is as true of the early days of legal abortion as it is today. But the way abortion is used in the 21st Century should not give rise to a sense of social and moral malaise – indeed quite the opposite. It is a way that many women take responsibility for their lives, their families and their futures.

Clare Murphy is head of public policy at bpas. bpas is sponsoring the debate Coarse sex and cheap lives at the Battle of Ideas festival, Saturday 29 October. See here for more information.

Coarse sex and cheap lives. By Clare Murphy. The Independent, 22 October 2011

Event: Best Medical Practice with Mifepristone: UK and international perspectives

Jennie Bristow reports from a conference held at St Thomas’s hospital, London, on 14 October. 

Back in the 1980s, those working in abortion services would not have dreamed of a time when women could safely and effectively manage their own abortions, through swallowing two drugs, provided widely and at low cost, and taken in the privacy of their own homes. But thanks to the ‘abortion pill’ – a combination of mifepristone and a prostaglandin (most commonly, misoprostol), home abortion in the first trimester of pregnancy has become a reality: at least, in some parts of the world.

The challenge for Britain is to work out how to make this reality happen here, where legal regulations actively prevent the use of best practice in early medical procedures.

This conference, funded by Nordic Pharma UK, offered perspectives on best practice with mifepristone from Mr Kamal Ojha MD, MRCOG, Consultant Gynaecologist at St George’s Hospital in London; Dr Christian Fiala MD, PhD, Medical Director of the Gynmed Clinic for Contraception and Abortion in Austria; and Dr Raha Shojai MD, Consultant in Obstetrics and Gynaecology at the North University Hospital of Marseille, France.

Introducing the conference, Kamal Ojha discussed the major difference that Early Medical Abortion (EMA – also known as the ‘abortion pill’ ) has made to the gestations at which abortions are performed in the UK. In 2010, three quarters of abortions in England and Wales were performed at under 9 weeks’ gestation, and as an abortion method EMA is growing in popularity relative to vacuum aspiration.
Some important safety and efficacy issues with EMA are continuing pregnancy following administration of mifepristone. On the first point, Mr Ojha explained, there are three issues: failed medical abortion, whether both mifepristone and the prostaglandin have been given; interrupted medical abortion, where mifepristone only is given; and a partially completed surgical abortion, where mifepristone has been given to soften the cervix prior to the procedure. The failure rate of EMA is low – 0.3%-1.5% of cases.  The other issues relate to a small number of reported cases, but highlight some interesting aspects of the widespread use of mifepristone.

For example, Christian Fiala’s talk began with a discussion of how mifepristone works. Its only effect, he explained, is that it stops the progesterone hormone from doing its job, thus making the uterus more sensitive to the prostaglandins used to open to the cervix, and separating the gestational sac from the uterine wall. For this reason it is effective more effective, he suggested, than misoprostol at cervical priming; which in turn, indicates its usefulness in areas such as IUD fitting.

Dr Fiala also argued that mifepristone has no teratogenic effect, and no feticidal effect. In later gestations, the fact that mifepristone is a gentler way of beginning the process of labour induction than the alternatives means that there can be a greater risk that the fetus may exhibit signs of life.

Dr Fiala stressed the synergistic activity of the two drugs used in EMA, which means that the dosage of mifepristone and misprostol should be discussed together. He spoke about the advantages of using a 600mg of mifepristone, in terms of reducing the pain of contractions induced by misoprostol. He went on to discuss the evidence about the clinical settings in which misoprostol should be administered, which he summarised as: 1) in the clinic, and the woman stays for two hours; 2) in the clinic, and the woman goes home immediately afterwards; and 3) at home. There is no evidence of benefit for the first two recommendations, he argued, while there is lots of evidence about the benefits of home use, and this is standard practice in the USA, Sweden and Austria.

Dr Fiala went on to discuss the question of whether there should be a lowest gestational age for EMA, arguing there is no reason to wait until it is possible to see a gestational sac on ultrasound and that β-hCG tests can be used to confirm that the procedure is successful. Ultrasound is often used because of concerns about ectopic pregnancy, but ‘we can handle this rationally’, he argued: a woman needs to be booked for a follow-up appointment anyway, so even in the rare cases where there is an ectopic pregnancy, no harm is done by starting on the EMA procedure provided care is taken one week later to ensure that the woman is no longer pregnant.

For Dr Fiala, we should handle patients presenting for very early ‘in the same way we do those with a miscarriage’. This is a recurrent theme in the EMA debate, as the experience of an early medical abortion is very similar to that of an early miscarriage, and there are similarities in the drugs used to manage it. For example in the UK, while it is illegal to give women misoprostol to take at home if she is undergoing an abortion, it is routine practice to give misoprostol to women who have experienced a miscarriage.

The management of home abortion was the theme of Dr Raha Shojai’s discussion of the clinical experience of, and guidelines relating to, EMA in France. Dr Shojai discussed some features of the abortion law in France, where it has been legal since 1975, and is available up to 14 weeks from the woman’s last menstrual period. There is a seven-day ‘cooling off’ period which can be reduced to 48 hours in cases where waiting may push women over the gestational limit – in practice, Dr Shojai implied, this loophole is widely used.

Medical abortion up to 49 days’ gestation is licensed in France to be performed outside of hospitals, meaning that provision has shifted away from hospitals to GPs’ surgeries and to the woman’s home. This has had many advantages in terms of reducing the waiting lists for abortion, and the cost of provision.  Women at these gestations can be orientated towards a hospital, clinic, office or home use: since 2005, said Dr Shojai, about 15% of abortions have taken place at home; and the results in terms of safety, acceptability, and patient choice have been highly positive. Practice has evolved such that women are often given both mifepristone and misoprostal to take at home.

Closing the conference, Mr Kamal Ojha discussed the recommendations relating to Early Medical Abortion in the forthcoming new guidance to be published by the Royal College of Obstetricians and Gynaecologists (RCOG), and chaired an open forum for discussion of the issues of the day.

Also read:

Abortion Review topic archive: Early Medical Abortion

UK: Interview with Louise Mensch

The anti-abortion MP talks to Catherine Lafferty of the Catholic Herald.

Lafferty writes:

She demonstrated her political fearlessness again earlier this month, as Nadine Dorries’s latest attempt to modify the law on abortion was falling to pieces, the victim of its own lack of preparation on the one hand and a ruthless onslaught by pro-abortion campaigners on the other. In rode Louise Mensch like a cowgirl, taking everyone by surprise by tabling her own amendment on abortion. She was blowing the smoke from her pistols as hardline pro-abortion activists were halted in their tracks, momentarily stunned by this unexpected move. For the first time the powerful pro-abortion lobby was on the back-foot. This was political artistry at a high level. So how did she do it? Her reply makes her strategy seem so deceptively simple you wonder why no one has tried it before.

“What I tried to do with my amendment was listen on the internet and Twitter, where I’m engaged to the pro-choice reaction to Nadine’s amendment, and try to answer every one of those objections and still achieve a pro-life goal by broadening abortion counselling,” she tells me.

Mensch’s amendment on abortion would have allowed providers like Life and Care to continue counselling but would have provided a “health warning”.

She explains: “That way nobody could say women were walking into an ideological trap. It would have said to a woman making a choice: if you wish to go to this provider they are an ideological organisation. I even stuck in the word ‘ideological’ as well as ‘faith’, as Life would say they are not a faith-based organisation. I was trying in my careful language to catch every pro-choice objection.”

In the event Mensch finally withdrew her amendment in what she describes as “a real crisis of conscience moment”, swayed by ministerial assurances that the Government was going to bring forward counselling changes anyway, but by then, as she notes, “the pro-life lobby had got itself into a real mess”.

Nonetheless, it is when she recalls the crucial moment that political reality clashed with a chance to reform abortion counselling that she expresses the only note of doubt during our interview.

“As pro-choicer after pro-choicer came up to me in the lobby saying: ‘We would have voted for your amendment’.

I regretted my decision,” she says. “Should the opportunity come up again, I will take it.”

As she talks about abortion, Mensch’s naturally rapid diction picks up even more speed, with her hands in constant motion in front of her. It’s as though you’re witnessing her quicksilver mind whizzing away, hypersensitive to the tiniest adjustment in political temperature. But it’s the quality of her analysis which is so impressive. Rarely have I heard such a clear-eyed dissection of abortion politics as that she outlined to me.

“I believe the pro-life movement constantly makes the perfect enemy of the good and that is why it fails,” she declares. “A first pragmatic step in pro-life politics – and I am pro-life – would be to acknowledge that this is a pro-choice country as a political reality and then say: ‘I am pro-life, how do I get my aim of reducing abortion through? The practical thing is there is a big pro-choice majority in the House of Commons and in the street and I can only achieve pro-life goals by doing it in a pro-choice way.’”

Perhaps one reason Mensch can think outside of the proverbial box on such a divisive issue as abortion is that she considers herself a feminist. She pays warm tribute to Nadine Dorries, who she describes as “a gutsy woman who has been unfairly demonised for her stance on abortion” and at the same time refuses to regard those in the pro-abortion camp as her enemies. More than once she says very emphatically that pro-lifers must not only stop demonising their opponents but try and imagine instead why they have reached different conclusions about the unborn child.

“I’m not comfortable with demonising counsellors and Marie Stopes and BPAS who are doing what they believe by their own lights and own morals what they believe to be right,” she says. “Of course what they’re doing I believe to be absolutely wrong, but they believe it to be right and I am not prepared to say they are not people of good will or they are motivated by money. In all kinds of politics it is always best to think well of your opponents and believe they are trying to get to the same goal by a different method.

“A good thing for a pro-life supporter to do would be to put themselves in the head of a pro-choicer,” she says. “If I didn’t believe the unborn child was a child, I would be as horrified as any pro-choicer because I would believe it was the most appalling interference in a woman’s body and a woman’s rights”…

Read the full interview here:

‘The pro-life lobby got into a real mess’. By Catherine Lafferty. Catholic Herald, 20 October 2011

Also read:

Abortion Review topic archive: Abortion counselling

UK: Repeat abortion among women in Britain

This study compares the characteristics of women who have presented for a second or subsequent abortion to those of women who have obtained only one. From Journal of Family Planning and Reproductive Health Care.

The authors note that around one in three sexually active women in Britain will have an abortion during their lifetime and a third of those women will experience more than one. In this study, using data collected during the second National Survey of Sexual Attitudes and Lifestyles, the characteristics of women who have presented for a second or subsequent abortion are compared to those women who have obtained only one.

Results indicate that increased age and parity are key characteristics distinguishing between women who have experienced only one abortion and those women who have had more. Findings also reveal that those who have sought abortion on more than one occasion are more likely (than those who have had one abortion) to be Black, have left school at an earlier age, be living in rented accommodation, report an earlier age at first sexual experience, be less likely to have used a reliable method of contraception at sexual debut and report a greater number of sexual partners.

The authors conclude that it is well recognised that attendance at abortion services presents an important opportunity for the provision of individually tailored information regarding contraception to assist women avoid the need for subsequent procedures. However, differential use of abortion services may also indicate variations in knowledge levels, attitudes to risk, attitudes towards abortion, partner communication, gender power and differential access to services. Further research is required to clarify these potential relationships so that suitable health promotion activities can be developed.

Centre for Sexual Health Research, School of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK.

Who presents more than once? Repeat abortion among women in Britain Nicole Stone and Roger Ingham. Journal of Family Planning and Reproductive Health Care 2011 Oct;37(4):209-15. Epub 2011 Jun 30.

UK: Can we identify women at risk of pregnancy despite using emergency contraception?

Data from a meta-analysis of two randomised controlled trials comparing the efficacy of ulipristal acetate (UPA) with levonorgestrel were analysed to identify factors associated with EC failure. From Contraception. 

The authors note that emergency contraception (EC) does not always work, and clinicians should be aware of potential risk factors for EC failure.

Data from a meta-analysis of two randomised controlled trials comparing the efficacy of ulipristal acetate (UPA) with levonorgestrel were analysed to identify factors associated with EC failure.

The risk of pregnancy was more than threefold greater for obese women compared with women with normal body mass index (odds ratio (OR), 3.60; 95% confidence interval (CI), 1.96-6.53; p<.0001), whichever EC was taken. However, for obese women, the risk was greater for those taking levonorgestrel (OR, 4.41; 95% CI, 2.05-9.44, p=.0002) than for UPA users (OR, 2.62; 95% CI, 0.89-7.00; ns).

For both ECs, pregnancy risk was related to the cycle day of intercourse. Women who had intercourse the day before estimated day of ovulation had a fourfold increased risk of pregnancy (OR, 4.42; 95% CI, 2.33-8.20; p<.0001) compared with women having sex outside the fertile window. For both methods, women who had unprotected intercourse after using EC were more likely to get pregnant than those who did not (OR, 4.64; 95% CI, 2.22-8.96; p=.0002).

The authors concluded that women who have intercourse around ovulation should ideally be offered a copper intrauterine device. Women with body mass index >25 kg/m(2) should be offered an intrauterine device or UPA. All women should be advised to start effective contraception immediately after EC.

University of Edinburgh, Scotland.

Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Glasier A, Cameron ST, Blithe D, Scherrer B, Mathe H, Levy D, Gainer E, Ulmann A. Contraception. 2011 Oct;84(4):363-7. Epub 2011 Apr 2.

UK: Tributes to a pioneer of abortion law reform

Reflections on the life and work of Madeleine Simms, 6 September 1930 - 3 October 2011.

Madeleine Simms, social rights campaigner and one of the architects of the 1967 Abortion Act, died on 3 October 2011. Obituaries in the Guardian and the Times (London) have paid tribute to Madeleine Simms’ powerful campaigning work, which played a crucial role in making abortion legal in Britain.

Madeleine Simms was author (with Keith Hindell) of Abortion Law Reformed and a founding trustee of Birth Control Trust. Here is the text of an interview, originally published in 1997, in which Simms explains her motivation for becoming an activist. It is an inspiring testament to those who brought the 1967 Abortion Act into being.

Below, Dilys Cossey OBE, former trustee of Birth Control Trust and former chair of the Family Planning Association, recalls the work she did with Simms in the Abortion Law Reform Association from 1964-1968.

Interview with Madeleine Simms in 1997, published in Abortion Law Reformers: Pioneers of Change.

In about 1960 I went to a Fabian Society lecture by Gerald Gardiner QC, who later became Lord Chancellor. He outlined a list of legal issues to which he thought the next Labour Government should apply itself. He just mentioned in passing that the abortion law needed to be reformed. This was the first time I became aware that abortion was illegal. In retrospect this seems rather odd, because I was already a 30-year-old married woman with a child. It shows how hidden the subject was then, that you could actually reach that stage in life and not quite understand what the position was about abortion.

I joined the Abortion Law Reform Association (ALRA). The Association didn’t seem to do very much, but I joined anyway.

We were the second wave of ALRA activists. Alice Jenkins and her friends Janet Chance and Stella Browne had founded ALRA in 1936. They did a lot of educational work and held meetings and conferences, but when the war came, the whole thing went into hibernation. When I joined 25 years later, there were a lot of elderly and rather respectable people running it, with an Indian army Colonel as the chair, which was not quite what I had expected. They were restrained and discreet. They felt you could hardly mention abortion in public, you could not write letters to the press about it, nor even to MPs unless you knew them personally. But in the 1960s we younger members started writing letters all over the place and found they were often printed. We showed that you could go into the House of Commons and not only talk to MPs about the subject, but pounce on the first few names drawn in the annual Private Members’ Ballot and ask the lucky MPs to sponsor an Abortion Bill. This was new – we probably pioneered this type of lobbying. Now of course everyone does it.

I became really active when the Thalidomide tragedy occurred. I have always been particularly concerned about the prevention of handicap, and it struck me as so appalling that there were people around who were actually prepared to compel women to have handicapped babies when this could be avoided. A friend of my parents had a brain-damaged son who grew far too big for her to handle; he was quite violent. It devastated her life. Seeing this at close quarters affected me. Until people have experienced the devastating affect on their own or a friend’s life of having a handicapped child, they do not always understand what the implications are for the mother and the whole family. There is a lot of sentimental talk about the joys of a lifetime’s caring, particularly on the part of those who do not have to do it themselves. If people choose to have a baby with Down’s Syndrome, that is their right. But the notion that you have the moral right to inflict your preferences on other people who are much less able to cope is monstrous.

So Thalidomide was my original motivation, but once you become involved in a cause, other issues come into play. I became very conscious of the social injustice involved. Middle-class women in a sense needed abortion law reform least because they could always buy abortions in Harley Street and could obtain them most easily. Working-class women often in desperate need had to go to the most appalling and often self-mutilating lengths and put themselves in great danger to obtain an abortion. Alice Jenkins, one of the founders of ALRA, wrote a book Law for the Rich, which particularly drew attention to the social injustice.

Another very important motivation was my love of children, and the horror that they might be born to women who did not want them, and who might therefore resent, neglect or abuse them. Children born in these circumstances often end up in care and in the courts. The notion that the law favoured inflicting unwanted children on hostile mothers makes no sense at all. I cannot understand why anyone should support such an idea – religion has a lot to answer for.

Some of our political opponents in the 1960s really did believe that those who were in favour of having children by choice not chance disliked children. So they were quite surprised that between us we had so many. I remember being amused by this thought when I was correcting proofs of an article about abortion law reform while sitting in bed at University College Hospital awaiting the birth of my second child.

I continue to be shocked by the notion of having a child carelessly. It is too important and far-reaching a decision to be undertaken lightly. It is a lifetime’s commitment, and only to be entered into with deliberation. It’s not like choosing a holiday or making some other trivial decision. If parents have children only when they really want them, this maximises the chances of the children having happy and successful lives, and this is what matters most.

The Steel Bill was not the ideal Bill. It was too hedged around by bureaucracy and restrictions. But I thought it was probably the best compromise we could achieve in the circumstances. It was scandalous that Northern Ireland wasn’t included, as long as it continued to be part of the United Kingdom, but at the time we nearly lost Scotland too. It was only because David Steel was a Scottish MP that we did not. I was unhappy about the absence of a straight social clause, but we had to settle for what we could – in this case the ‘medico-social’ clause as it came to be called. We had to fight hard to save even that. David Steel was under enormous pressure to cut down his Bill. I greatly admire what he did and regard him as one of the great unsung heroes of the women’s movement, but he was desperate, as MPs are in these circumstances, to achieve an Act of Parliament. We knew we could not go through all this again in a hurry, so we had to ensure that we obtained a major reform, which we did.

Years later the Abortion Act seems inadequate and restrictive, however advanced it appeared in the 1960s. This is inevitable. Perspectives change over time. I don’t think the abortion decision should be up to doctors, it should be the decision of women. They are the only ones who can truly judge their social and emotional resources. It seems obvious now that abortion should be available on request at least in the first three months of pregnancy, and thereafter on serious grounds. It should be treated like any other operation, and not hedged round by special regulations, for two doctors to agree, and legal notification, and all the rest of it. At that time, of course, doctors did not want their authority taken away from them and handed to patients. They said in effect: ‘We know best’.

The 1967 Act enshrines this attitude, which is my chief objection to it. On the whole doctors now recognise that they can’t know best in this particular context, though they generally do of course know best about the technical aspects of the operation, which is anyway becoming more simple all the time. Most doctors now recognise that it is not up to them to deny women birth control or abortion if that is what the women require. Of course, in the 1960s, Roman Catholic MPs and doctors were as opposed to contraception as they now are to abortion. People have forgotten that, and Roman Catholics do not much like to be reminded of this now. A series of national opinion surveys have shown that a majority of Catholic voters now support abortion law reform, even surprisingly in Northern Ireland, and this despite all the pressure on them from the Church and their politicians.

Despite my reservations, I do think the Abortion Act was an enormously important reform. It has enabled anyone who needs an abortion on grounds of serious handicap to obtain it, and there has been a huge increase in access for working-class women. There are still problems. But, yes, I do think reforming this law was a great thing to do. It was also an important international landmark which had tremendous influence in changing the abortion laws in Europe and America and throughout the developed world. I am enormously proud of having been a part of it. It is the most useful thing I have ever helped to do in my life and I am grateful to have had the chance to participate in such a campaign.

The group of people who came together in the 1960s was formidable. Getting to know them well was one of the marvellous side effects of being so closely involved in this cause. I suppose it was in the spirit of the age to some extent. Reform was in the air. We were getting rid of the last bits of Victorian baggage that were surplus to requirements – the 1861 Offences Against the Person Act in our case. The whole thing could not have taken off without Vera Houghton, our chair, who was a superb co-ordinator of all our individual and slightly chaotic efforts. She was the only one of us with previous high-level political and administrative experience both in her own right and with her husband, the greatly-respected Labour MP Douglas Houghton.

I remember it primarily as a parliamentary campaign. I always loathed demonstrations, of which there were many by the 1970s, and always marched rather unwillingly, doubting how effective this form of mindless activity was. But the Catholics did it so we felt we had to as well. I preferred sitting at those round tables in the lobby of the House of Commons helping MPs to write speeches. I remember the great excitement when the Bill finally went through, having stayed up all night, then going out in the morning to find a barrow selling coffee and buns off Parliament Square.

I am a bit sad that my own children are not involved in this sort of campaign, though they and my husband have been wonderfully supportive of my activities. I feel they are really missing out on something. Making common cause with people brings very close ties. It is natural in a way that young people today are a little complacent about abortion because they have grown up taking for granted that it is legal and safe. But if you look across the Atlantic you can see how threatening it can be if you do not keep up the pressure.

The 1967 Abortion Act has helped a new generation of women plan their lives and careers in a way that very few women of my generation were able to. If you are confident that you can control your fertility you can afford to be ambitious and compete with men for the really interesting, worthwhile and powerful jobs. This is beginning to happen now and it is wonderful to witness.

I have often heard people say at meetings that the Abortion Act was the result of the women’s movement, but this isn’t so. The women’s movement did not really start until the 1970s. The 1960s campaign for abortion gave impetus to the women’s movement. It brought women together and showed that, by concentrating their efforts on a central issue, they could achieve something. I think this example encouraged women to come together on other issues too. It was a stepping stone to the whole feminist rising in the 1970s and 1980s. I hope it will continue.

Dilys Cossey, ALRA secretary from 1964-1968, writes:

In autumn 1963 I had my introduction to three powerful women, when I was interviewed for the job of Secretary of the Abortion Law Reform Association (part-time, £2 per week, working from home) by Vera Houghton, Madeleine Simms and Diane Munday in the Marsham Court flat of Vera’s husband, the Labour MP Douglas Houghton. 

Madeleine’s quiet, almost ladylike demeanour – a result perhaps of all those years at St Paul’s Girls’ School - which was what I first observed about her, hid a passionate commitment to women’s rights, a strong intellect, formidable writing skills and a mischievous sense of humour. As ALRA’s press officer she used every opportunity to write letters to the press – and was sometimes known to use another name both to initiate a correspondence as well as respond to letters under her own name. The newsletter is now a historic record of ALRA’s progress over the crucial four years of the campaign. 

The ALRA campaign was a way of life. Madeleine with two young children coped with her responsibilities by concentrating on family matters during the day and worked late into the evening on ALRA affairs. 

My main memory of Madeleine is her intellectual curiosity and enquiring mind. She was a voracious reader and would send me a copy of items she thought would interest me in a book she was reading. Biographies of famous people were rich source of such examples.  A pithy comment would sometimes be added. 

Madeleine Simms obituary. By Suzie Hayman. Guardian, 12 October 2011

Madeleine Simms obituary. The Times, 10 October 2011

Abortion Law Reformers: Pioneers of Change Interviews with people who made the 1967 Abortion Act possible. BPAS 2007 [First published by Birth Control Trust 1997]

UK: World population nearing seven billion

The Times (London) carries an interesting set of articles on the ‘overpopulation’ question.

The Times reported on 8 October that the global population is ‘set to touch seven billion by end of month’.

‘This seven-billion moment is the culmination of an astonishing transformation in human fortunes. For in the last Ice Age, about 20,000 years ago, Homo sapiens was close to extinction’, reports the Times. ‘We numbered just a few tens of thousands: we were as endangered a species as our close cousin, the orang-utan, is today.

‘Back then, the average person occupied an area roughly the size of Hampshire. Today, each of us occupies an area the size of Hampshire’s cricket ground. And most of the population expansion that has so crowded the planet has taken place since 1960.’

Under the headline ‘Will cities rise to the challenge or is this the tipping point?’, the Times carries a debate between Mark Stevenson, author of An Optimist’s Tour of the Future, and Chris Rapley, professor of climate science at University College, London. Stevenson argued that population is ‘a good thing’:

‘It’s easy, like Rosling’s students, to agonise about the imminent birth of the 7 billionth person. But in fact, the “population problem” is well on the way to solving itself. The rate of growth has been slowing since the mid-Sixties and according to the UN’s “median variant estimate” (a sort of statistician’s best guess) will hit zero sometime towards the back end of the century, at which point there will be around 10billion of us.

‘Part of the reason for this is increasing urbanisation, which has two bits of good news. First, people in cities have fewer children. Second, high population densities in cities make it cheaper and easier to provide education, healthcare, sanitation and power.

‘So the teeming metropolis, often seen as a totem to planetary destruction, is actually an engine of renewal, not least because cities are also catalysts for innovation, hosting the academics and entrepreneurs who are developing ways to deal with our grand challenges.
‘There are, of course, plenty of challenges in hosting 10 billion of us, but none of them is insurmountable (if we have an optimism of ambition). It’s easy to get down on humanity but we rather ignore the figures that show that, as we grow in number, we fight less and collaborate more, all while innovating our socks off. Imagine the creative geniuses lurking in the next 3 billion.’

Rapley, on the other hand, wrote that the seven billion figure is ‘bad news’:

‘The optimists will say a greater head-count increases the pool of talent. And it is true that on an otherwise finite planet, human ingenuity appears unbounded. But each additional person requires food, water and energy to survive, and a society with decent housing, schooling, and medical care in which to flourish. Already 1 billion people have no access to clean water, and 2.5 billion don’t have proper sanitation. Addressing this is challenge enough. To do so for a further 2 billion is daunting. What can we do?

‘Satisfying the need for family planning services would be a start. This could slow the rate of population increase by more than a third. Eliminating extreme poverty, thus stimulating the demographic transition in which birthrates fall, would also help. This would provide relief to technological and behavioural initiatives aimed at achieving greater sustainability.’

The presumed need for promoting family planning, as a way of controlling population growth, is stressed by Sir John Sulston, the Nobel prize-winning biologist and chair of the Royal Society study People and the Planet, who writes:

‘It’s an uncomfortable subject for politicians; the idea of influencing family size has unpleasant associations with state coercion. But population does need to be talked about. Rising numbers and the associated consumption of resources is putting an unsustainable load on Earth. That is why the Royal Society, the national academy of science, has begun a comprehensive study, which I am chairing.

‘Since 1950, the global population has swelled almost threefold. The current population of almost seven billion is forecast to rise to more than nine billion by 2050. This is increasing demands on the finite resources of our planet, reducing our ability to bring people out of poverty and causing climate-warming increases in carbon dioxide in the atmosphere, a decline in biodiversity and conflict for resources.

‘There should be a deafening chorus calling for global debate and action, but there isn’t. Part of the problem is its complexity; it’s not simply a case of “more people”. While in some countries fertility remains high, in others it is very low. For example, because of plummeting birth rates, increasing life expectancy and little immigration, Japan’s greying population is set to shrink. The same is true in Western Europe…

‘There are no quick fixes, but that does not mean that we can ignore it. Although science cannot provide all the solutions, it does have a key role to play. During my lifetime, science has made huge strides in addressing humanity’s great challenges: new methods of energy generation, for example, bring electricity to people in deprived areas.

‘But great as these achievements are, science is not the whole story. We need socio-economic structures that distribute goods more fairly, reducing the damaging effects of excessive consumption in the rich countries and lifting the least developed out of poverty. We need to provide universal education that empowers young people to take control of their lives and bodies. Through education and the provision of reproductive health and family planning services women can choose to have fewer, healthier, thriving children. Yet 215 million women around the world still lack the basic right to choose when to have children and their desired family size.’

A leader in the Times, however, gives a less bleak perspective on the issue. On 8 October, the paper argued:

‘The past century has seen a rapid quickening of population growth. It took the world population millions of years to reach the first billion but only 123 years to get to the second billion, 33 years to get to the third and only 27 years to get from there to the fifth. The sixth and seventh billions have taken just 12 years each. As medicine has improved around the world, and the quality of food improved out of all recognition in the world’s successive agricultural revolutions, life expectancy has grown. A British boy born in 1800 could expect only to live into his early forties. Now he can expect almost twice as long a life.

‘This evident good news, which is spreading around the globe, brings with it many concerns about the battle over scarce resources, such as water. There are already one billion people in the world who have no access to clean water or electricity. There are 2.5 billion who have no effective sanitation.

‘The present concerns are made all the more worrying because it is the poor parts of the world that are growing fastest. Ninety per cent of population growth is taking place in developing countries in Africa and Asia which raises the prospect, in the minds of the alarmed, that destitution caused by population growth in the third world will show itself in demands on immigration into developed countries. The fear can incite authoritarian solutions such as compulsory state birth-control policies.

‘In fact, the answer to the fears about population growth are essentially the same now as they were in the last years of the 18th century. Three years before Malthus wrote, the French mathematician and social scientist, Condorcet, predicted that the problem of population growth would be solved by reasoned human action. Increases in productivity and better education of the people would change behaviour and allow the world to sustain a greatly enlarged population.

‘This is, indeed, what has happened. Economic and social development has been accompanied by big reductions in birth rates and the emergence of smaller families as the norm. As Europe and North America underwent industrialisation, this was the pattern they experienced. The period of greatest population growth coincided with the greatest recorded growth in living standards.

‘This is why economic growth remains the key to the population debate. The other great intellectual ferment of the latter years of the 18th century was the argument about the merits of free trade, given its most eloquent expression in Adam Smith’s The Wealth Of Nations. It is still true that trade between free nations is the best way of ensuring that the ingenuity of enterprising human beings is harnessed for a growing population. Where there are shortages, they are caused by the poor having inadequate entitlement to food, not by an overall shortage of food.’

In an interesting article published on OpenDemocracy on 18 October Danny Dorling, professor of human geography at the University of Sheffield, argues that the United Nations Population Division (UNPD)’s projection of global population growth ‘fails to take account of global “baby-boom” peaks and troughs over the past sixty years’. He claims that ‘worldwide we experienced a baby-boom during the past decade that peaked in 2006. The previous boom peaked in 1986, and the one before that, in 1966. Progressively fewer children were born in the 1986 and 2006 peaks because contraception had become more popular worldwide and infant mortality was falling.’

Dorling goes on to argue: ‘My interpretation of recent world population projections, along with evidence that economic inequalities between nation states are falling, suggest to me that our current obsession with border controls could seem as quirky and sad to future generations as, say, the racist demand that black people sit at the back of the bus – or in another bus entirely – seems to us today’.

Global population set to touch seven billion by end of month. The Times (London), 8 October 2011

Will cities rise to the challenge or is this the tipping point? The Times (London), 8 October 2011

Overpopulation is too big a problem to ignore. The Times (London) 10 October 2011

The Population Bomb. The Times (London), 8 October 2011

Possible ‘peak population’: a world without borders? By Danny Dorling. OpenDemocracy, 18 October 2011

Also read:

Abortion Review topic archive: Population debate

Testing in the First Trimester - Providing women-centred care

Report on the conference organised by Antenatal Results and Choices in London on 19 September 2011.

The charity Antenatal Results and Choices (ARC) provides support and information to women and couples undergoing antenatal testing, and to those who have taken the decision to terminate a pregnancy following a diagnosis of fetal anomaly. These diagnoses often take place in the second, even third, trimesters of pregnancy, and the decision to abort a wanted pregnancy can be emotionally traumatic and practically challenging.

While abortion for fetal anomaly is legal and available as part of National Health Service (NHS) care, there are only a small number of clinicians prepared to carry out ‘late’ abortions in the UK. Women terminating pregnancies in later gestations may not be offered a choice between medical induction and surgical abortions, which can make a deeply upsetting experience even more so.

This is the backdrop against which ARC organised its 2011 conference, focusing on the issue of ‘Testing in the first trimester’. In her presentation to the conference Jane Fisher, director of ARC, talked about the advances that have been made in high-quality first-trimester antenatal screening programmes and their national implementation. The earlier in pregnancy that fetal anomalies can be accurately diagnosed, the better this is in terms of women’s ability to access the terminations they may need.

However, said Fisher, ‘we should not assume that earlier diagnosis reduces the emotional impact on parents’, as ‘the news that they are not expecting the healthy baby they had envisaged is devastating for parents whatever the gestation’. And while the technology used in antenatal testing has improved enormously, it is still far from perfect: ‘many parents have to contend with an uncertain outlook for their baby’, and it is important that individuals in this situation ‘have access to clear evidence-based information and individualised support and are enabled to make the choices that are right for them in their individual context’.

Organising better screening across the NHS

The advances that have been made in first trimester screening are both technological and organisational. The NHS Fetal Anomaly Screening Programme (FASP) was launched in 2009 to bring antenatal screening practices across the NHS in line with national standards, and to drive improvements in accuracy. Mrs Pat Ward, National Programme Director for FASP, gave a useful presentation on the ‘weaknesses and strengths’ of the programme to date.

A major gain of this programme has been to increase the number of hospitals using the combined screening test, which takes place between 11 and 13 weeks of pregnancy, and involves a combination of the nuchal translucency (NT) measurement - a scan of the fluid at the back of the fetus’s neck - and a blood sample from the pregnant woman. As a glossary on the ARC website explains, ‘Together with the mother’s age, these are used to estimate her chances of having a pregnancy with Down’s syndrome. If the chance is more than 1 in 150 (although this may vary with different hospitals) a diagnostic test, such as CVS, will be offered’.

The combined test is more accurate than the previously used double, triple or quadruple tests, and Ward’s presentation explained that full implementation of the combined test has been ‘a major undertaking of the national screening programme’. As things now stand there is 97% implementation in all hospitals of this strategy: a major improvement on a few years ago. This test has led to a fall in ‘false positive’ rates, which reduces the proportion of unnecessary further invasive tests, such as CVS or amniocentesis, which carry a risk of miscarriage. 

More details about improvements in combined testing were the subject of a presentation by Rachel Sharman, Regional Obstetric Screening Co-ordinator for the South East Coast, who explained the way that FASP has improved standards NT measurement through training Sonographers and auditing their results.

The presentations by the Fetal Anomaly Screening Programme highlighted the gains that have been made through better organisation of antenatal screening across the NHS. Some other fascinating presentations discussed advances in the technology of prenatal testing, which hold out further possibilities for improvement.

New advances in prenatal testing

Professor Lyn Chitty, Professor of Genetics and Fetal Medicine at University College London, gave an interesting presentation titled ‘Non-invasive prenatal diagnosis using cell free fetal DNA – the future of prenatal diagnosis’. Cell free fetal DNA, explained Chitty, is detectable from four weeks’ gestation, and is already used for the detection of fetal sex (in cases of sex-linked inherited disorders) and Rhesus negative status.

There is the potential for a number of other applications, in the development of maternal blood tests for conditions such as Down’s Syndrome , and Chitty discussed the work carried out by the RAPID (Rapid Accurate Prenatal non-Invasive Diagnosis) programme, a five-year UK national programme funded by the National Institute for Health Research. There have been some solid and exciting scientific developments in this area, and the possibility of the test being routinely used in antenatal care continues to come closer.

The presentation by Professor Steve Robson, Professor of Fetal Medicine at Newcastle University, asked: ‘Is it time to replace conventional karyotyping for fetal anomalies?’ Karyotyping is a test to examine chromosomes in a sample of cells in order to help identify genetic problems as the cause of a disorder or disease, which can be done through testing tissue such as blood or amniotic fluid. Robson talked about new developments in the test Array Comparative Genomic Hybridization (ACGH), which is used to detect genomic copy number variations.

The development of this technique is important, not least because it could help to diagnose conditions that might not otherwise be detected: for example, certain ‘micro-deletion syndromes’ that can affect structural and mental development in the fetus. However, Robson cautioned that there are a number of challenges that should be considered before introducing this technology into mainstream prenatal screening: primarily to do with the severity and nature of a condition that might be indicated by variations. Just because we can see a particular association, he said, does not means that it is ‘worth knowing about’ in terms of what it will mean for the baby being born; and as with all technologies, we should be careful about how they are introduced.

Robson noted that the more structural abnormalities that can be detected on ultrasound, the more likely the fetus is to have a chromosomal abnormality. This was also a point brought out by Professor Kypros Nicolaides, Director of the Harris Birthright Research Centre, London, whose work with the most difficult cases of fetal anomaly is known and admired internationally. Nicolaides noted that, when a case of a condition such as Down’s Syndrome is suspected, further investigation may show that the fetus does not have that condition, but that it does have another abnormality. From this he argued that greater sensitivity to checking for anomalies during routine ultrasound scans may lead to better detection: as he said, when measuring the crown-rump length of the fetus, it does not take much to check other structural details at the same time.

Nicolaides also raised a question about whether the current ‘pyramid of pregnancy care’ that informs antenatal monitoring, which has been in use in Britain for almost a century and emphasises close monitoring in the last few weeks of gestation, should be re-thought in the light of developments in first-trimester screening. As problems with the fetus can increasingly be diagnosed at around 12 weeks, he suggested that there may be a case for referring those women for specialist care, whilst having fewer interventions later on with women with whom a problem has not been identified.

Ethics, emotions and choices

Mando Meleagrou, Head of the Psychotherapy Consultation Service for Maternity Patients at Harris Birthright Research Centre for Fetal Medicine, London, gave a powerful presentation about the patient’s experience of receiving a diagnosis of fetal anomaly. She emphasised the importance of understanding that a woman is pregnant with a ‘baby in her mind’ as well as the baby in her body; thus a diagnosis of fetal anomaly can bring a complex emotional response to do with the woman’s own hopes, anxieties and experiences.

The discovery of abnormality can reveal, in ‘external reality’, someone’s ‘most disturbing thoughts and worst fears’; and when women say they have been robbed of their pregnancy by such a diagnosis, they are referring to their hopes and expectations about the ‘baby in their mind’ as much as to the fetus they are carrying. 

A presentation on ‘Choosing, choice and the measurement of quality’, by Dr Louise Bryant, Lecturer in the Psychology of Healthcare at the University Leeds, discussed some of the challenges to informed choice that first-trimester screening might present to women. Although it appears to be highly acceptable to both women and clinicians and offers a number of advantages over second-trimester screening, Bryant explained that there are some issues to do with ‘information overload’, where a newly-pregnant woman might find herself overwhelmed by the number of decisions she has to make, and things to has to think about, at that stage in her pregnancy.

Bryant also suggested that there are some problems with the ‘informed choice’ model used in healthcare, in that it can assume that there is a ‘right’ behaviour that a woman can be manipulated into if she is given particular information. Conversely, she noted that healthcare staff can sometimes be so concerned not to be seen as being directive that they do not dare to give women advice that they need. 

Patricia Lohr, Medical Director of BPAS, discussed the role that the independent sector can play in the termination of pregnancy for fetal anomaly. Noting that the Royal College of Obstetricians and Gynaecologists recommends that, wherever possible, women terminating a pregnancy because of a fetal anomaly should be offered the choice of a medical or surgical procedure, Lohr talked about the disparity in choice of method between independent sector clinics, such as those run by BPAS and Marie Stopes International, where surgical abortion dominates provision, and NHS hospitals, where the proportion of procedures performed surgically declines dramatically as gestational age advances

Independent sector clinics currently perform over half (59%) of all abortions in England of Wales, the vast majority of which are funded by the NHS. However, terminations for fetal anomaly tend to take place in NHS hospitals, which means that these women are often, in practice, only able to access the method of medical induction.

Lohr noted that there can be good reasons for using this method - for example, if there needs to be a post-mortem examination of the fetus, or if a woman wants the ‘rites and rituals’ surrounding a birth. In other cases, however, the safety of surgical methods, and the preference of some women for these methods, means that the independent sector could play a greater role in collaborating with the NHS to perform terminations for fetal anomaly, where this best fits the need of the woman. Research indicates that neither method is ‘best’ for a woman’s emotional experience, but what does make a difference is that she has been able to make the choice.

Report by Jennie Bristow, editor, Abortion Review.

Also read:

Clinical Update: Termination of Pregnancy for Fetal Anomaly. By Jane Fisher, Director of Antenatal Results and Choices (ARC). Abortion Review, 4 October 2011

Prenatal screening: What do women need to know, and why? Jennie Bristow reports on the launch of the NHS Fetal Anomaly Screening Programme. Abortion Review, 29 May 2009

Abortion Review topic archive: Fetal anomaly

Clinical Update: Termination of Pregnancy for Fetal Anomaly

By Jane Fisher, Director of Antenatal Results and Choices (ARC).

Q) What is meant by termination of pregnancy for fetal anomaly?

Termination of pregnancy for fetal anomaly (sometimes shortened to TOPFA) is used to refer to abortions that are classified under Ground E of the Abortion Act 1967 (as amended in 1990). These are abortions that are carried out when two clinicians are satisfied that: ‘There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped’.

In England, Scotland and Wales, terminations under Ground E are legal beyond the ‘time limit’ of 24 weeks’ gestation that applies to most abortions. According to Department of Health statistics, 2,290 abortions were performed under Ground E, in 2010. This represents about just over 1% of the total number of abortions carried out in England and Wales. (1) A total of 147 abortions were carried out over 24 weeks’ gestation; less than 0.1% of all abortions.

Abortions in these circumstances are usually referred to as ‘terminations’ by healthcare professionals and the women involved. This is perhaps an attempt to categorise them as being performed for medical reasons and to differentiate them from the ending of unwanted pregnancies.

Q) At what gestation does TOPFA generally take place?

Although the law allows for TOPFA beyond 24 weeks, the vast majority (over 96%) happen before this. The timing tends to correspond with the scheduling of antenatal screening and diagnostic tests. There are two types of diagnostic tests: ultrasound scans, and the invasive diagnostic tests for chromosomal and some genetic conditions - chorionic villus sampling (CVS) and amniocentesis. There is an optional universal screening programme for Down’s syndrome in England, Scotland and Wales.

In England, most women are offered a first-trimester combined screening test. (2) This is carried out between 11 and 13 weeks’ gestation and involves an ultrasound scan and maternal blood test. More common in Scotland and Wales is a maternal blood test performed at around 16 weeks. This test is also provided to those women who book into antenatal care too late for the earlier screening. Even if a woman chooses not to have Down’s syndrome screening, she will still have a scan between 10 and 12 weeks to date the pregnancy. Major structural problems can be seen at this early scan.

The provision of earlier screening in England was partly driven by the principle that by having an earlier result, women could access the earlier diagnostic test (CVS) which is carried out between 11 and 14 weeks. This could then allow for earlier reassurance, or if, after the confirmed diagnosis of an anomaly, a woman decides to end the pregnancy, there would be a choice between surgical and medical management of the termination process.

In reality, due to the lack of surgical expertise in NHS settings, most women will be offered a medical termination if they receive a diagnosis beyond 13 weeks. Currently, few are told they may be able to access a surgical procedure through an independent provider. Women who have a blood test to screen for Down’s syndrome between 16 and 20 weeks’ gestation and whose result leads to the offer of a
diagnostic test will have the option of an amniocentesis. The major scan to check for structural problems in the developing fetus is performed between 18+0 and 20+6 weeks gestation. (3) Problems seen at this scan will usually require further investigations.

A proportion of TOPFAs are therefore performed after 20 weeks’ gestation. Within the NHS these are always medically managed, with feticide recommended at gestations beyond 21 weeks 6 days. The small number (147 in 2010) of TOPFAs performed after 24 weeks are usually due to a condition that is detected later in the pregnancy. For example, a woman may present at 28 weeks for a scan to check placental
position and a brain abnormality is detected. Or in some cases women may have been monitoring the progression of a condition diagnosed at the mid-pregnancy scan and then find the prognosis deteriorate in the third trimester.

Q) What are the reasons why women would choose a particular method of termination?

There is no research evidence that the method used to end a pregnancy after a prenatal diagnosis will complicate the post-procedure emotional recovery. (4) From ARC’s extensive experience in supporting women and couples post TOPFA, the key factor seems to be that they are enabled to have it managed in the way they can best cope with at the time. They will require clear information on their care options and should be given the time they need to decide how to proceed. There will be some instances when a detailed post-mortem is recommended and so medical management will be necessary.

It can be difficult for women to contemplate going through labour and delivery to end a wanted pregnancy, but after the initial shock at the idea, some will decide that this method feels more ‘natural’ and a more tangible way of managing the loss. There will be an intact fetus and this gives women and their partners the choice to see and hold their baby if this is what they want; but there is no clear evidence to suggest that seeing and holding the baby will lead to less complicated grieving. Other women decide that the surgical option under general anaesthetic will be easier for them to cope with than a medically-managed delivery.

There are no particular clinical skills required by TOPFA.

Q) What are the other considerations in dealing with women presenting for TOPFA?

Most women who present for TOPFA will be grieving the ‘healthy baby’ they have already lost and distressed that they are ending a wanted pregnancy. Some will be very sensitive to the fact that they may come up against women using abortion services who are in different circumstances with pregnancies that are unwanted. They may feel the need to make it clear to staff that theirs is a wanted pregnancy and that they are only ending it because of the severity of the condition affecting the fetus.

Women facing TOPFA can feel very vulnerable. Although they know intellectually that they are making the right decision in their situation, emotionally there can be painful conflicting feelings. Some will fear
judgement from others for ending a pregnancy because a life-limiting or disabling condition has been diagnosed (this can partly be due to them judging themselves harshly for deciding on termination). Because distress levels can be high, many women will be keen to have their partner with them for support for as much of their time in clinic as possible if this is practicable.

Women presenting for TOPFA will often conceptualise their pregnancy as a ‘baby’ rather than a fetus and may need reassurance from clinical staff that the procedure will not cause the fetus pain. Some may want to see the screen when having a scan pre-procedure, while others may wish to distance themselves from this pregnancy. There will be women who rapidly want to look ahead to the next pregnancy, which may mean they wish to opt out of discussions about contraception. It can be useful for women to be given contact details of ARC in case they wish to seek emotional support after the procedure as they can be taken aback by the grief reaction they experience once they return home.

As will all women seeking abortions, the key to the sensitive management of TOPFA is to not make assumptions, take the cue from an individual woman and try as far as possible to accommodate her needs.

Jane Fisher is Director of Antenatal Results and Choices (ARC). For more information about ARC’s services go to www.arc-uk.org or call 02076310280. For more information on TOPFA see the RCOG’s 2010 Working Party Report Termination of Pregnancy for Fetal Abnormality.

This article appears in the print edition of Abortion Review, Number 35, Summer 2011. Download a .pdf of this issue of Abortion Review here.

Also read:

Abortion Review topic archive: Fetal anomaly

Abortion Review topic archive: Clinical Update Q&A

References

(1) Department of Health. Abortion Statistics, England and Wales: 2010. Statistical Bulletin 2011/1.London: DH 2011

(2) NHS Screening Programmes: NHS Fetal Anomaly Screening Programme

(3) NHS Screening Programmes: NHS Fetal Anomaly Screening Programme

(4) Statham H. ‘Prenatal diagnosis of fetal abnormality: the decision to terminate the pregnancy and the psychological consequences.’ Fetal and Maternal Medicine Review 2002;13:213–47.

USA: Woman’s Right to Know Act challenged on grounds of free speech and privacy

The American Civil Liberties Union and four other groups sued to challenge a new North Carolina law requiring abortion providers to display and describe ultrasound images of a fetus, the Los Angeles Times reports.

The suit, filed in federal court on 29 September, alleges that the statute violates the constitutional rights of women and healthcare providers and intrudes on women’s private lives.

“Politicians have no business forcing healthcare providers to push a political agenda on their patients,” Bebe Anderson, senior counsel for the Center for Reproductive Rights, which joined in the suit, said in a statement.

The statute, passed by the Republican-controlled state Legislature in July over the veto of Democratic Gov. Bev Perdue, also requires a 24-hour waiting period for women seeking an abortion.

The suit seeks an injunction to block the law, which is set to take effect on 26 October.

Legal challenges have temporarily blocked similar laws in Texas and Oklahoma. At least 20 states have passed laws that require ultrasounds for women seeking abortions, and North Carolina is the third state to require a provider to place ultrasound images in a woman’s line of sight and to describe them in detail, the LA Times reports.

The North Carolina statute also requires providers to offer women an opportunity to listen to the “fetal heart tone.” A woman may avert her eyes and refuse to listen, but the bill otherwise makes no exceptions, according to the ACLU.

“The law forces a doctor, while performing an ultrasound, to describe the embryo or fetus and put pictures in front of the woman’s face even if the woman says she doesn’t want to see them,” Katy Parker, legal director for the ACLU of North Carolina Legal Foundation, said in a statement.

There was no immediate comment from legislative sponsors of the statute.

The lawsuit, which names as defendants the president of the state Medical Board and several state officials, alleges that the Woman’s Right to Know Act is unconstitutional - specifically, its “display of real-time view requirement” and “informed consent to abortion” provisions. The ultrasound provision “forces patients to allow their bodies to be treated as the source for government-mandated speech, treats women as less than fully competent adults . . . and chills the exercise of constitutional rights,” the lawsuit alleges.

The requirement that providers give women state-mandated information about abortion within 24 hours of any procedure is “impermissibly vague,” the lawsuit says, and contends that the statute violates constitutional rights to “due process, free speech, privacy, liberty, bodily integrity and freedom from unreasonable searches and seizures.”

Along with the ACLU and the Center for Reproductive Rights, the plaintiffs are Planned Parenthood Health Systems and Planned Parenthood of Central North Carolina.

State Rep. Ruth Samuelson, a Republican from Charlotte and a sponsor of the legislation, said in June that the statute is “about respecting women.” “This bill keeps abortion legal. It keeps abortion safe,” Samuelson told reporters when the measure passed. “And, by golly, we know it helps make it more rare. It is still her choice. It makes it her informed choice.”

ACLU challenges new N.C. abortion law in court. Los Angeles Times, 29 September 2011

Sweden: Comprehensive counselling about combined hormonal contraceptives

This was a cross-sectional multicentre study, set in seventy Swedish family planning clinics, which aimed to study the influence of counselling on women’s contraceptive decisions. From Acta Obstetricia et Gynecologica Scandinavica.

The population was women aged 15-40 years attending for a contraceptive consultation who expressed interest in a combined hormonal contraceptive (CHC) method. The survey methods were structured counselling about three CHCs and questionnaires completed after counseling from the healthcare professional.

The main outcome measures were method originally requested, perceptions of CHC attributes, method chosen and reasons for the choice.

In all, 173 healthcare professionals and 1,944 women participated. The mean standard deviation (SD) age of the women was 22.6(6.1) years. After structured counseling, a majority of women (56.0%; n=1 069; 95% confidence interval (CI) 53.1-58.9) chose the daily pill, 6.2% (n=118; 95% CI 4.9-7.8) chose the weekly patch, and 22.5% (n=430; 95% CI 20.2-25.1) chose the monthly ring. The weekly patch was chosen more often after counselling (6.2 vs 2.4% before counseling; p<0.0001). The greatest change was in the proportion of women who chose the contraceptive ring after counselling (22.5% vs. 8.5% before counseling; p<0.0001). The proportion of undecided women after counselling was reduced considerably (3.9% vs. 27.8% before counseling).

Among the 523 women who were undecided before counseling, 50.6% chose the pill, 10.2% the patch and 24.6% the ring, while 20.9% of women who initially requested the pill changed to another method.

The authors concluded that structured counselling facilitated choice of contraceptive method for most women, leading to changes in women's selection of a CHC method.

Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, Stockholm, Sweden.

Comprehensive counseling about combined hormonal contraceptives changes the choice of contraceptive methods: results of the CHOICE program in Sweden. Gemzell-Danielsson K, Thunell L, Lindeberg M, Tydén T, Marintcheva-Petrova M, Oddens BJ. Acta Obstetricia Gynecologica Scandinavica. 2011 Aug;90(8):869-77. doi: 10.1111/j.1600-0412.2011.01180.x. Epub 2011 Jun 20.

© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.

Event: What does it mean to be pro-choice today?

Report on a lively public discussion organised by the Voice for Choice coalition in London. 

The climate surrounding abortion in Britain is changing: maybe not dramatically, but enough to give us pause.

The New Labour government, from 1997 to 2010, wore its pro-choice credentials on its sleeve by improving access to abortion earlier in pregnancy, increasing the proportion of abortions funded by the NHS, and promoting improved access to abortion through provision by independent sector clinics: primarily, the charities BPAS and MSI.

However, the New Labour government also fought shy of addressing abortion directly as a political issue, and in 2008, took the unusual step of guillotining Parliamentary debate about the Human Fertilisation and Embryology (HFE) Bill in such a way that pro-choice amendments could not even be debated. To the anger of pro-choice advocates, long-overdue changes to Britain’s forty-year old Abortion Act, including removing the requirement that two doctors have to authorise a woman’s abortion and allowing women to take the second dose of the early medical abortion ‘pill’ at home, could not even be considered.

With the election of the Conservative/Liberal Democrat Coalition government in 2010, in a time of economic crisis, a number of changes are being undergone at the level of the National Health Service and the welfare state as a whole. Those working in sex education and contraceptive provision have felt the direct pressure of public sector cuts, and while there have been no proposals to alter the core funding and main infrastructure of abortion services, there is a distinct chill in the political climate.

In 2011 alone, the Department of Health has strongly resisted attempts by abortion providers to bring clinical practice around the abortion pill into line with that of other countries, and removed BPAS from a forum concerned with the implementation of sexual health policy, whilst adding the anti-abortion group Life. Recently, debate about the government’s major reform of the NHS, to be brought about through its flagship Health and Social Care (HSC) Bill, was engulfed by a wave of controversy surrounding an amendment proposed by the anti-abortion MP Nadine Dorries, which was designed to change the way abortion counselling is provided.

The Dorries amendment failed spectacularly in a Parliamentary vote. But the fact that this non-problem was able to attract so much political and media attention, and be taken seriously by the Department of
Health, indicates that pro-choice advocates cannot assume that the argument for access to high quality abortion care in Britain has been won. It was in this context that Voice for Choice organised a public meeting to discuss what it means to be pro-choice today, chaired by the Guardian journalist Libby Brooks.

Patricia Lohr, medical director of BPAS, spoke first from the perspective of working as an abortion doctor, both in the USA and the UK. She described how she become involved in pro-choice activism at university, physically defending women’s ability to access an abortion clinics during protests organised by the anti-abortion group Operation Rescue. For Lohr abortion is a feminist issue – it is to do with questions of agency and access, and allowing women and children the best chance of the best life they can have. For doctors working under threats of violence and intimidation, as in the USA, ‘you need to know about the risks but act in defiance of them’, she said.

Evan Harris, the former MP for Oxford West and Abingdon who, in 2007, brought together the influential Science and Technology Committee’s report Scientific Developments Relating to the Abortion Act 1967, gave a rousing and humorous speech about what it means to be a pro-choice politician in the current climate. He began by remarking upon the problem of UK universities often being ‘too intolerant’ of anti-abortion movements, which often banned by student societies – these issues, he said, are best debated out in the open.

The Dorries amendment, said Harris, resulted in a total defeat for Nadine Dorries – but not in a total victory for pro-choice campaigners, as the Department of Health has remained stubbornly committed to holding an inquiry into abortion counselling services. Harris went on to lambast the ‘wasted opportunity’ of the previous 13 years, when there was a massive pro-choice majority in Parliament, yet nothing was done to update the 1967 Act.

Of the pro-choice amendments that were put down in 2008, the call to extend the 1967 Abortion Act to Northern Ireland is not, Harris indicated, worth pursuing: ‘power is devolved, and the UK government will never be able to deliver that’. But the other changes – including the ‘ridiculous rules’ around Early Medical Abortion – should continue to be pushed for.  He pointed out the absurdity of the abortion pill regulations:  ‘there’s nothing in the British air’ to make women’s ability to administer the second EMA drug at home any different to that of women in other countries, ‘but the government says we need trials in Britain – then stop them halfway through because they say it’s illegal to hold these trials.’

Harris concluded by noting that the 1967 Act was a ‘remarkable piece of legislation and has served us well’, but we need to go beyond it. He was critical of the extent to which pro-choice voices in the previous government put all their energy into defending the 24-week ‘time limit’ for abortion at the exclusion of other, positive improvements that should have been pushed for as well. If you ask for big improvements, he argued, you are more – and not less – likely to achieve other things as well. Harris concluded by arguing that ‘Parliament has a right to discuss these issues’, rather than, for example, talking out Private Members’ Bills.

The implication of Harris’s speech was that the timidity of the pro-choice movement in 2008 prevented it from making the progress it should have made, and that there has been a tendency to shy away from debating abortion for fear of rocking the boat and making things worse. We are now paying the price for hiding behind the status quo: the possibility for improving the Abortion Act has receded, and the possibility of it becoming even more restrictive has become closer.

The final speaker was Marge Berer, editor of the journal Reproductive Health Matters, who focused on the point that while the public health argument for abortion has been accepted, the ‘moral right’ of the case for abortion has not yet been won. ‘There is something about women not having total control over their reproductive lives that is not totally accepted’, she argued; and the challenge for the pro-choice movement is to carry on trying to win that argument.

Berer discussed the trend towards the anti-abortion lobby adopting ‘clever’ messages that abortion hurts women – as in the Dorries amendment, which implied that current pregnancy counselling pushes women to have abortions that they don’t want. These tactics cause a major headache for pro-choice advocates, who ‘have to waste a lot of time responding to untrue claims’, and also have to defend the most weak and vulnerable cases – women having late abortions, or abortions for conditions such as cleft palate.

The issues of previous abortion and contraception were also touched on by Berer, who criticised the pejorative nature of the phrase ‘repeat abortion’ - it implies that young women are having abortions one after the other, when in fact the risk of previous abortion rises with parity (women who already have children); given the number of times a woman ovulates over the course of her reproductive life, the ‘contraceptive failure’ represented by one, two or even three abortions is remarkably low. Long-Acting Reversible Contraceptives (LARCs) – such as the implant, coil or injection - are often mistakenly discussed as the ‘magic bullet’ that will automatically bring abortion numbers down, but the reality is more complicated than that.

The presentations were followed by an animated discussion from the audience. Questions were raised about the extent to which the pro-choice movement in the USA and Britain may have conceded too much, when they have accepted that abortion should be made ‘safe, legal and rare’; the continuing problems with contraceptive provision and the acceptability of LARCs; the relationship of abortion politics to scientific evidence; and the gulf between the priorities of policymakers, who see contraceptive efficacy as the main question, and women’s experiences of contraception, which is bound up with a number of more subtle issues to do with their relationship and their feelings about sex.  There was also some discussion about what the abortion issue means to a younger generation of women, who have grown up seeing the issue de-politicised and taking it, to some extent, for granted.

The meeting concluded that to be pro-choice today requires being open to engaging with a number of new and old challenges, and taking a robust approach to pushing for improvements in law and clinical practice whilst also defending the status quo against those who would restrict provision further. There is no need to panic about abortion provision in Britain at the moment – but the current circumstances should shake elements of the pro-choice movement out of any complacency it may have had in the recent past.

The Voice for Choice public meeting was held at the Medical Society of London on 22 September. Jennie Bristow is editor of Abortion Review.

USA: Alternatives to ultrasound for follow-up after medication abortion: a systematic review

The authors concluded that alternatives to routine in-person follow-up visits after medication abortion are accurate at diagnosing ongoing pregnancy. From Contraception.

The authors note that requiring a follow-up visit with ultrasound evaluation to confirm completion after medication abortion can be a barrier to providing the service.

The PubMed (including MEDLINE), Cochrane Central Register of Controlled Trials and POPLINE databases were systematically searched in October and November 2009 for studies related to alternative follow-up modalities after first-trimester medication abortion to diagnose ongoing pregnancy or retained gestational sac. The authors calculated the sensitivity, specificity, positive predictive value and negative predictive value compared with ultrasound or clinician’s exam. We also calculated the proportion of cases in each study with a positive screening test.

The search identified eight articles. The most promising modalities included serum human chorionic gonadotropin measurements, standardized assessment of women’s symptoms combined with low-sensitivity urine pregnancy testing and telephone consultation. These follow-up modalities had sensitivities ≥90%, negative predictive values ≥99% and proportions of “screen-positives” ≤33%.

The authors concluded that alternatives to routine in-person follow-up visits after medication abortion are accurate at diagnosing ongoing pregnancy. Additional research is needed to demonstrate the accuracy, acceptability and feasibility of alternative follow-up modalities in practice, particularly of home-based urine testing combined with self-assessment and/or clinician-assisted assessment.

Ibis Reproductive Health, Oakland, CA 94612, USA.

Alternatives to ultrasound for follow-up after medication abortion: a systematic review. Grossman D, Grindlay K. Contraception. 2011 Jun;83(6):504-10. Epub 2010 Oct 8.

European ruling may ban women from knowing the sex of their fetus

The Sunday Telegraph reports on a draft resolution to be considered by the Council of Europe in October. 

Medical staff should be instructed to “withhold information about the sex of the fetus” according to a draft resolution passed by a Council of Europe committee, the Sunday Telegraph reports. The plan is an attempt to prevent parents “selectively aborting” fetuses – usually female – as means of “choosing” the sex of their child. The recommendation covers all 47 member states, meaning all NHS midwives and doctors could be blocked from telling expectant parents whether they will have a boy or a girl.

Justine Roberts, founder of parenting site Mumsnet, said that expectant parents asked to know the sex of their child on practical grounds, such as working out whether siblings could share a room, or simply because they wanted an idea of what lay ahead. “I can understand that there may be problems in some parts of the world with sex selection, but it seems ridiculous to apply the thinking to countries where this has not been shown to be a problem,” she told the Sunday Telegraph. “I think pregnant women would feel pretty angry and disappointed to be told they can’t be told the gender of their unborn child.”

The Council of Europe, based in Strasbourg, cannot impose binding orders on governments but is highly influential in policy-making and has often seen its decisions enacted through conventions and treaties. The draft resolution by the council’s equal opportunities committee will now go before the council’s full Parliamentary Assembly for approval next month.

In the UK, most maternity units are happy to tell expectant parents the gender of their fetus, if they want to know. Sometimes parents are told during the 12 week scan – if it is clear that the baby is a boy – and otherwise at the 20 week stage, when a more detailed scan is undertaken.

But a few NHS trusts have policies which deny parents the option, either because of concerns about prenatal sex selection, or on cost grounds. Colchester Hospital Foundation trust reversed its policy one month ago after a pregnant woman campaigned for the right to know the sex of the baby she was carrying.

Natalie Mann, 30, a university lecturer from Clacton, Essex, was furious when the hospital would not tell her the gender of her fetus, at 20 weeks, so she could tell children Maisie, four, and Eliza, two if they would have a baby brother or sister. From this month, the trust has increased funding for the service, allowing 30 minutes rather than 20 for the scan, which it said gave staff time to find out the unborn baby’s gender.

The draft resolution by the Council of Europe, passed on 9 September, states that prenatal sex selection has reached “worrying proportions” in several member states, in particular Armenia, Azerbaijan and Albania, where the ratio is 112 boys for 100 girls, and in Georgia, where the ratio is 111 boys for 100 girls. It calls for an investigation into the causes of the skewed birth ratios in these countries, and says prenatal sex selection should only be allowed in order to avoid serious hereditary disease linked to one sex. But their recommendation that all public hospitals in all 47 states should not tell parents the gender of their unborn child caused alarm, the Sunday Telegraph reports.

Dr Gillian Lockwood, medical director of Midland Fertility Services, said it would be difficult for hospitals to follow the advice, given that in some cases, parents would be able to work out the gender for themselves, while looking at the scans. She said that while she had seen a few couples who were prone to “Victoria Beckham syndrome” – being desperate for a girl, after several boys, or vice versa – most only wanted to know their unborn baby’s gender so they could paint the nursery, buy suitable clothes, or tell other children whether they would have a brother or sister.

Dr Lockwood, former vice-chairman of the Royal College of Obstetricians and Gynaecologists’ ethics committee, also said it was hard to see how the European recommendations would prevent selective abortions in this country, given that so many received the news about the baby’s gender at 20 weeks, when it would be impossible to secure a termination without medical grounds. She said couples who were prepared to abort selectivelyon the grounds of gender were more likely to resort to blood tests, which are not yet legal in this country, but sold on the internet, which disclose the gender at seven weeks, when abortions could be secured.

The committee is composed of 77 MPs and politicians from member states, with British members including Labour MPs Ann Coffey (Stockport) and Yasmin Querishi (Bolton South East) Conservative MP Amber Rudd (Hastings and Rye) and Lib Dem peer Baroness Emma Nicholson. The recommendation, which will be discussed by the full assembly of 318 MPs from 3 to 7 October, calls on them to “consider recommending public hospitals to instruct doctors to withhold information about the sex of the fetus, or at least ensure that this information is given in a positive way, irrespective of the sex of the fetus.

A spokesman for the Department of Health said it would not comment on the resolution until it was passed but said the main purpose of scans was to check for abnormalities, and to date the fetus, not to identify the sex. He said decisions on whether or not to disclose the possible gender of the child should be “based on the clinical judgment of the certainty of the test and the individual circumstances of each case.”

An investigation carried out by the Sunday Telegraph on 25 September 2011 reported that ‘a survey of maternity units in England discloses that several are already refusing to share the information’: hospitals in Watford, St Albans and Hemel Hempstead in Hertfordshire, and Luton in Bedfordshire say they are too busy to determine the sex of the fetus during scans to check for abnormalities, while in Telford and Shrewsbury, in Shropshire, pregnant women who want to know if they are expecting a boy or a girl have to pay to find out.

The hospital trusts running the units said parents would only be told the sex of the fetus if there were special medical reasons, such as the chance of a child inheriting a condition which is gender specific. Couples who simply want to know which colour to paint the nursery - or to tell existing children whether they will be having a baby brother or sister, are reprotedly told that they can only find out by going private.

All the trusts insisted their policies were drawn up because of tight resources, not concerns about selective abortion.

Cathy Warwick, general secretary of the Royal College of Midwives (RCM) said there were “no ethical reasons” to deny such information to women to women in this country.

The RCM suggested that some hospitals might be more worried about the costs of litigation, if their prediction was wrong, than about extra screening time if the position of the fetus made it hard to establish the gender.

Breedagh Hughes, the RCM’s spokeswoman on ethics, said: “I think some hospital trusts have had some very painful experiences of litigation, when families have been told they are expecting a boy, and painted the nursery every shade of blue, only to find out that they are expecting a girl. As far as I am aware, none of these cases have succeeded, but they can still cause trusts a whole load of trouble in legal costs.”

Parents could be barred from knowing the sex of their unborn baby by European ruling. Sunday Telegraph, 11 September 2011

Maternity units refuse to tell parents the sex of unborn babies. Sunday Telegraph, 25 September 2011

UK: Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic

This study involved a systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion. From Bulletin of the World Health Organisation. 

The study set out to compare medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability.

A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Popline were searched. Failure to abort completely, side-effects and acceptability were the main outcomes of interest. Odds ratios and their 95% confidence intervals (CIs) were calculated. Estimates were pooled using a random-effects model.

Nine studies met the inclusion criteria (n = 4522 participants). All were prospective cohort studies that used mifepristone and misoprostol to induce abortion. Complete abortion was achieved by 86-97% of the women who underwent home-based abortion (n = 3478) and by 80-99% of those who underwent clinic-based abortion (n = 1044). Pooled analyses from all studies revealed no difference in complete abortion rates between groups (odds ratio = 0.8; 95% CI: 0.5-1.5). Serious complications from abortion were rare. Pain and vomiting lasted 0.3 days longer among women who took misoprostol at home rather than in clinic. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.

The authors concluded that home-based abortion is safe under the conditions in place in the included studies. Prospective cohort studies have shown no differences in effectiveness or acceptability between home-based and clinic-based medical abortion across countries.

The full text of this article is available to read for free here.

Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, England, UK.

Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review. Ngo TD, Park MH, Shakur H, Free C. Bulletin of the World Health Organisation. 2011 May 1;89(5):360-70. Epub 2011 Mar 4.

USA: Effectiveness and acceptability of medical abortion provided through telemedicine

The study aimed to estimate the effectiveness and acceptability of telemedicine provision of early medical abortion compared with provision with a face-to-face physician visit at a Planned Parenthood affiliate in Iowa. From Obstetrics and Gynecology. 

Between November 2008 and October 2009, the authors conducted a prospective cohort study of women obtaining medical abortion by telemedicine or face-to-face physician visits. We collected clinical data, and women completed a self-administered questionnaire at follow-up. We also compared the prevalence of reportable adverse events between the two service delivery models among all patients seen between July 2008 and October 2009.

Of 578 enrolled participants, follow-up data were obtained for 223 telemedicine patients and 226 face-to-face patients. The proportion with a successful abortion was 99% for telemedicine patients (95% confidence interval [CI] 96-100%) and 97% for face-to-face patients (95% CI 94-99%). Ninety-one percent of all participants were very satisfied with their abortion, although in multivariable analysis, telemedicine patients had a higher odds of saying they would recommend the service to a friend compared with face-to-face patients (odds ratio, 1.72; 95% CI 1.26-2.34). Twenty-five percent of telemedicine patients said they would have preferred being in the same room with the doctor.

Younger age, less education, and nulliparity were significantly associated with preferring face-to-face communication. There was no significant difference in the prevalence of adverse events reported during the study period among telemedicine patients (n = 1,172) (1.3%; 95% CI 0.8-2.1%) compared with face-to-face patients (n = 2,384) (1.3%; 95% CI 0.9-1.8%) (82% power to detect difference of 1.3%).

The authors concluded that provision of medical abortion through telemedicine is effective and acceptability is high among women who choose this model.

Ibis Reproductive Health, Oakland, California, and Cambridge, Massachusetts 94612, USA.

Effectiveness and acceptability of medical abortion provided through telemedicine. Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Obstetrics and Gynecology. 2011 Aug;118(2 Pt 1):296-303.

USA: Committee opinion no. 501: Maternal-fetal intervention and fetal care centres

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics make recommendations regarding informed consent, the role of research subject advocates and other independent advocates, the availability of support services, the multidisciplinary nature of fetal intervention teams, the oversight of centres, and the need to accumulate maternal and fetal outcome data. From Obstetrics and Gynecology. 

The abstract notes that the past two decades have yielded profound advances in the fields of prenatal diagnosis and fetal intervention. Although fetal interventions are driven by a beneficence-based motivation to improve fetal and neonatal outcomes, advancement in fetal therapies raises ethical issues surrounding maternal autonomy and decision making, concepts of innovation versus research, and organizational aspects within institutions in the development of fetal care centres.

To safeguard the interests of both the pregnant woman and the fetus, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics make recommendations regarding informed consent, the role of research subject advocates and other independent advocates, the availability of support services, the multidisciplinary nature of fetal intervention teams, the oversight of centers, and the need to accumulate maternal and fetal outcome data.

Committee opinion no. 501: Maternal-fetal intervention and fetal care centers. American College of Obstetricians and Gynecologists. Committee on Ethics; American Academy of Pediatrics.Committee on Bioethics. Obstetrics and Gynecology. 2011 Aug;118(2 Pt 1):405-10.

France: Medical vs. surgical abortion: the importance of women’s choice

Using a large national sample of women undergoing an abortion in France, the authors explore the factors associated with medical or surgical abortion, drawing particular attention to the influence of women’s preferences in the decision-making process. From Contraception.

The data are drawn from a nationally representative survey of 8245 women undergoing an elective abortion in France in 2007. Analyses of factors associated with the type of abortion technique were performed among the 4650 women who were identified as being eligible for the two techniques.

Sixty-eight percent of all abortions were medical procedures among women eligible for both techniques. The type of abortion technique was not dependent on women’s age, parity, cohabitation status, socioeconomic circumstances nor on the type of facility providing the abortion (private or public). Conversely, women’s participation in the decision-making process was strongly associated with the type of abortion method. Among the 50% of women who reported they had been given a choice, 84% underwent a medical procedure vs. 52% of those who were not offered a choice. Among the 2286 women who were not involved in the decision, 35% indicated they trusted their doctor to make the best choice for them, while 44% were told it was too late for a medical procedure, although they had consulted before 8 weeks of amenorrhea.

The authors concluded that in this sample of French women who participated in a national survey on abortion, those who were involved in the decision-making process as to whether to have a medical or surgical procedure showed a strong preference for the medical procedure.

Medical vs. surgical abortion: the importance of women’s choice. Caroline Moreau, James Trussell, Julie Desfreres, Nathalie Bajos. Contraception, Volume 84, Issue 3, September 2011, Pages 224-229

Thailand: Outcomes of pregnancy termination by misoprostol at 14-32 weeks of gestation

This is a a retrospective, descriptive study based on a 10-year-experience of misoprostol use at Maharaj Nakorn Chiang Mai Hospital. From the Journal of the Medical Association of Thailand. 

Based on the authors’ prospective database, all pregnancy terminations by misoprostol between 14-32 weeks of gestation between 1998 and 2008 were reviewed. The main outcomes included success rate of termination, mean induction-to-abortion time, and complication rate. In addition, regimens and routes of drug administration as well as indications for termination of pregnancy were also analysed.

Seven hundred forty one pregnancy terminations were performed using misoprostol with dosage varied from 50 mcg to 800 mcg, mostly 400 mcg intravagina every three hours. The most common indication for pregnancy termination was severe fetal thalassemia (35.8%). The majority of cases were pregnancies with live fetuses and only 18.2% were associated with a dead fetus in utero. Success rate of termination within 48 hours was 85.9%. Pregnancies with previous cesarean section accounted for 8.6% of cases. The mean gestational age was 20.94 weeks. The mean abortion time was 25.35 hours, ranging from 1.25 to 247.88 hours. The two most common adverse effects were chill and fever (43.7% and 34.3%). The rate of analgesia needed was 39.3%. No serious adverse complications such as uterine rupture were found

The authors concluded that this experience suggests that misoprostol has a high efficacy for pregnancy termination with acceptable minor side effects and it is relatively safe when used with precaution.

Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Outcomes of pregnancy termination by misoprostol at 14-32 weeks of gestation: a 10-year-experience. Pongsatha S, Tongsong T. Journal of the Medical Association of Thailand. 2011 Aug;94(8):897-901.

Event: Abortion debates at the Battle of Ideas 2011

BPAS is sponsoring three sessions at this London festival, 29-30 October 2011: ‘How late is too late?’; ‘Coarse sex and cheap lives’, and ‘What is feminism for?’

Coarse sex and cheap lives

Saturday 29 October, 3.30pm until 5.00pm

Every year, about 200,000 women in England and Wales will have an abortion; and one in three will have an abortion over her lifetime. With the development of the ‘abortion pill’, pregnancies at under nine weeks’ gestation can be terminated by women swallowing two pills, and abortion providers are arguing for women to be able to take the second of these pills at home, leading to the further ‘de-medicalisation’. Beyond the traditional pro-choice, pro-life divide, there is a concern that Britain’s high abortion numbers reflect a culture where sex and intimate relationships are treated casually and human life is de-valued. Has abortion become ‘too easy’, and so normal that moral questions about the value of fetal life are being ignored? Or might we evolve a new sexual morality reflecting genuinely-held feelings rather than prudery or prurience?

Speakers

Anne Atkins, novelist, columnist and broadcaster

Ann Furedi, chief executive, British Pregnancy Advisory Service

Sue Matthias, editor, FT Weekend Magazine

Yvonne Roberts, journalist, broadcaster and novelist

William Saletan, journalist and author of Bearing Right: how conservatives won the abortion war

Abortion: how late is ‘too late’?

Sunday 30 October, 10.45am until 12.15pm

International concern about the problem of late abortions was sparked in January when the horrific story emerged of a Philadelphia doctor charged with providing illegal late abortions and infanticide in the USA. In the 2008 debate about Britain’s abortion law, a number of parliamentarians argued for lowering the ‘time limit’ for abortion. Advances in ultrasound images make us sensitive to how early on in pregnancy a fetus looks like a baby; discussions about the development of fetal pain often suggest a late-term fetus ‘feels’ like a baby too. New state laws passed in the USA often focus on restricting later term abortions, including those carried out for fetal anomaly. What do we know about why women have late abortions? Is there a moral difference between early and late abortion - and if so, where in pregnancy can that line be drawn? Can choice be meaningful if it is limited? 

Speakers

Ann Furedi, chief executive, British Pregnancy Advisory Service

William Saletan, journalist and author of Bearing Right: how conservatives won the abortion war

What is feminism for?

Sunday 30 October, 3.45pm until 5.15pm

The stereotypical Bluestockings and dykes in dungarees have undergone a makeover in recent decades, with ‘third wave’ feminists often wearing heels and lipstick, and arguing modern feminism is about being who you want to be. Where feminism used to focus on the problem of ‘patriarchy’, and shared causes such abortion rights and equality at work, many newer feminists balk at grouping women together under any shared banner. Feminists always had some differences when it came to ideas about abortion, motherhood and pornography: but can they now agree on anything? Does third wave feminism represent a liberation from the crankiness of the old feminists - or is it just a form of intellectual bimbo-ism, slapping a feminist badge on personal preferences? Was feminism ever an ideology that could change the world? Are men the problem, or not - and has anything really changed?

Speakers

Anna Percy, poet

Nina Powell, researcher in psychology, University of Birmingham

Helen Reece, reader in law, LSE

Cathy Young, contributing editor, Reason magazine; author, Ceasefire! Why women and men must join forces to achieve true equality

Zoe Williams, columnist, Guardian; author, Bring it on, Baby

The Battle of Ideas is hosted by the Royal College of Art, London, SW7 2EU. For further information and to purchase tickets, see the Battle of Ideas website.

Also read:

Late abortion: the new clash in the Choice Wars. Philadelphia’s ‘Baby Butcher’ scandal shows exactly why we need a principled defence of abortion - as late as necessary. By Ann Furedi. Abortion Review, 3 March 2011

Coarse sex and cheap lives. By Clare Murphy. The Independent, 22 October 2011

China: Chromosomal abnormalities in patients with recurrent spontaneous abortions

This study aimed to investigate the ratio and types of chromosomal abnormalities in patients with recurrent spontaneous abortions (RSAs). From the Journal of Reproductive Medicine.

In this study, cytogenetic results of 734 patients with RSA, 360 men and 374 women, were referred to Norman Bethune Medicine College, Jilin University, Changchun, China, from May 2004 to December 2009. Among these 734 patients, 172 were couples. Gbanded cytogenetic analysis was performed based on our standard laboratory protocols, and results were given based on International System for Human Cytogenetic Nomenclature 2005 and 2009.

Of the total 734 patients, 22 patients were found to have abnormal karyotypes, which were believed to cause RSA. Eight of them were men (1.09%) and 14 were women (1.91%). The chromosomal abnormalities detected include reciprocal translocation (2.45%), dicentric abnormality (0.14%), Robertsonian translocation (0.27%), and inversion (0.14%).

The authors concluded that chromosomal abnormality is an important cause of RSA. It is very important to provide chromosomal analysis service for patients with RSA, and it should be considered as a standard medical care.

Center for Reproductive Medicine of the First Hospital, Jilin University, Changchun, People’s Republic of China.

Chromosomal abnormalities in patients with recurrent spontaneous abortions in northeast China. Zhang Z, Gao H, Li S, Hong M, Liu R. Journal of Reproductive Medicine. 2011 Jul-Aug;56(7-8):321-4.

USA: Fetal pain, abortion, viability, and the Constitution

The authors offer a substantive biological, ethical, and legal critique of the new fetal pain rationale. From the Journal of Law and Medical Ethics. 

The authors note that in early 2010, the Nebraska state legislature passed a new abortion restricting law asserting a new, compelling state interest in preventing fetal pain.

In this article, they review existing constitutional abortion doctrine and note difficulties presented by persistent legal attention to a socially derived viability construct. They then offer a substantive biological, ethical, and legal critique of the new fetal pain rationale.

Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, MA, USA.

Fetal pain, abortion, viability, and the Constitution. Cohen IG, Sayeed S. Journal of Law and Medical Ethics. 2011 Summer;39(2):235-42. doi: 10.1111/j.1748-720X.2011.00592.x.

USA: Intrauterine device insertion after medical abortion

This was a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion. From Contraception. 

The authors note that studies comparing immediate intrauterine device (IUD) insertion after first-trimester surgical abortion with interval insertion show similar efficacy and expulsion rates. However, women randomized to interval insertion of an IUD are less likely to return for device placement. An ideal time to insert intrauterine contraception may be the day a woman presents for verification of a completed medical abortion. The authors examined immediate insertion of IUDs after completed first-trimester medical abortion.

This was a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion.

Of 118 subjects, 78 women had levonorgestrel IUDs placed, whereas 41 women received copper IUDs. Of 97 subjects who completed the study, there were 4 clinical expulsions (4.1%) during 3 months of follow-up. There were no diagnosed pelvic infections, pregnancies, or uterine perforations. The continuation rate at 3 months was 80%.

The authors concluded that intrauterine devices inserted at the time of completed, confirmed first-trimester medical abortion have low rates of expulsion.

Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.

Intrauterine device insertion after medical abortion. Betstadt SJ, Turok DK, Kapp N, Feng KT, Borgatta L. Contraception. 2011 Jun;83(6):517-21. Epub 2010 Dec 3.