17 May 2012
Event: Debating the gap between policy and practice
The BPAS conference ‘Pills in Practice’, held at London’s Royal Society of Medicine on 11 May 2012, brought together renowned speakers from Britain, Europe and America to discuss how abortion and contraception policy can best meet the needs of women in the 21st century.
Abortion has been much in the news in recent months, and often in ways that have generated more heat than light. From ‘sex selection’ abortions to the ‘scandal’ of pre-signed HSA1 forms, it has never been clearer that the issues with abortion provision that preoccupy many journalists, politicians and policymakers can be worlds away from the things that preoccupy women who need abortions and the professionals who care for them.
Britain’s abortion service: Prospects and barriers
The ‘Pills in Practice’ conference opened with a discussion by Ann Furedi, chief executive of BPAS. Furedi began by noting that ‘Providing a good abortion service is not that difficult ... when politicians keep their noses out of it’. She went on to outline the legal and regulatory framework that surrounds abortion provision in Britain, which she described as ‘relatively reasonable’. This follows ‘two decades of progress’ in which abortion services have been publicly funded and a number innovations have been made to improve the flexibility of the service and the experience of women accessing it, from nurse-led provision and localised early treatment services to the provision of choice of treatment method and the ability for women to self-refer into a service.
This progress reflects a broader ‘cross-ideological consensus’ that women have a role in public life, sex is about more than procreation, contraception is not infallible, and that parenthood should be planned and wanted. The result has been an acceptance that abortion is a necessary back-up to contraception – it remains stigmatised but also often considered a responsible course of action in a woman experiencing an unwanted pregnancy.
So what are the barriers to continued improvement in abortion care? One recent development has been the emergence, in and around government, of a rather more negative view of abortion than that which has prevailed in policy circles over the past two decades. This has been illustrated by politically-motivated attempts to undermine the credibility of abortion clinics and their staff, and to trivialise women’s reasons for needing abortion: as epitomised by the decision by the Health Secretary, Andrew Lansley, in March to instruct the Care Quality Commission (CQC) to carry out a series of ‘unannounced inspections’ on abortion clinics throughout the UK to ensure that doctors are complying with the ‘spirit and the letter’ of the 1967 Abortion Act: a move that has been discussed elsewhere on Abortion Review.
In a similar vein, the Department of Health is currently conducting a consultation on abortion counselling, which arose in response to the failed attempt by Nadine Dorries, the noted anti-abortion MP for Mid Bedfordshire, to pass a parliamentary amendment to the Health and Social Care Bill that would strip abortion providers of the ability to provide women with information, advice and counselling. The ‘counselling consultation’ does not seem to be based on any actual evidence of a problem with abortion counselling, which has been provided by clinics for many years and has been established in this way for very good reasons. (See the BPAS briefing ‘bpas briefing: Abortion Providers and Pregnancy Advice’, here). At the same time, real and pressing problems with women’s access to the contraception they need to protect themselves from unwanted pregnancy in the first place appear low down the list of government priorities – and policy to guide family planning services, which could help prevent these pregnancies, is now a year overdue.
Home abortions: Do we medicalise too much?
Where policymakers really could make a positive improvement to abortion provision, they have dug their heels in and refused to allow practice in Britain to be brought into line with the rest of the world. This was exemplified back in January 2011, when Department of Health lawyers aggressively – and successfully - fought a High Court challenge brought by BPAS, which argued for an interpretation of the Abortion Act that would allow women to take misoprostol, the second medication involved in Early Medical Abortion (the ‘abortion pill’ ), at home.
The practice of ‘home use’ of misoprostol is standard in many other countries, including the USA; and at the ‘Pills in Practice’ conference Beverly Winikoff, President of Gynuity Health Projects in the USA, gave a keynote speech outlining the innovations and improvements that have been made in that country with medical abortion in the early stages of pregnancy. Essentially, the ‘abortion pill’ – a combination of the drugs mifepristone and misoprostol, which need to be taken 24-48 hours apart – has allowed for a significant ‘demedicalisation’ of abortion for women with pregnancies of under 9 weeks. The service is nurse-led, and the abortion itself can be woman-led – to the extent that where women are permitted to take one or even both of the drugs home with them, they can ‘time’ their abortion around what best suits them; for example, weekends or when their partner is home from work to take care of the children.
The Early Medical Abortion (EMA) regimen has demonstrable ability to allow terminations to be provided earlier in gestation, at greater ease and convenience for women and making full use of the skills of nurses and midwives. Winikoff’s presentation demonstrated the pioneering research and practice that is being done elsewhere in the world to see whether EMA can be used at slightly later gestations, according to different dosages of the medication, and with more effective and less intrusive methods of follow-up. It seems increasingly bizarre that British abortion providers are prevented from following these opportunities through enforced adherence to a law developed to regulate clinical practice of the 1960s, where abortions were surgical operations that had to be performed by doctors within a hospital setting.
Other speakers in this session outlined international clinical and legal perspectives on the issue of ‘home abortions’. Sam Rowlands, of Dorset University Healthcare Trust and the University of Warwick, presented an overview of the regulation of abortion pills worldwide. Kate Greasley, Lecturer in Law at Hertford College, Oxford, presented an excellent legal critique of the court’s decision in the 2011 BPAS High Court challenge over home use of misoprostol.
Raha Shojai, from North University Hospital of Marseille, France – the country where the ‘abortion pill’ was first developed – explained how clinics in that country have developed a way of providing Early Medical Abortion that better meets the needs of women, yet amidst quite stringent regulations. Kinga Jelinksa, project manager for the Dutch organisation Women on Web, which provides abortion pills to women in countries where abortion is illegal, discussed how these medications have allowed a situation to develop where women are able to get around restrictive laws to perform their own abortions, in a way that is relatively safe. In this global situation, questions need to be asked about the point of unreasonable regulations – as women are clearly capable of getting around them when they need to.
Contraception: LARCs and their limits
As for preventing unwanted pregnancy – how can contraception policy best meet the needs of British women? A session debated the ways in which the positive contribution that has been made by new Long-Acting Reversible Contraceptives (LARCs) to find a more effective method of birth control than the condom and the pill.
James Trussell, Professor of Economics and Public Affairs at Princeton University and visiting Professor at the Hull York Medical School, discussed the impact of a project that aims to explain in better, and more balanced, detail the advantages of LARC methods. For Trussell, women’s ability to choose more effective methods are often compromised by lack of adequate information, and a policy focus that aims these methods primarily at teenagers, sidelining older women.
Dawn Clark, psychologist at the London Research Centre for Therapeutic Education, raised a number of concerns with the way that the policy framework risks imposing contraception upon young women, rather than allowing them choices and control. She discussed how pejorative language around ‘repeat abortion’, which borrows on the discourse of ‘repeat offenders’, presents young women seeking abortion as a deviant group, rather than as individuals for whom an abortion is something that happens in a specific context and for particular reasons. Clark suggested that the presentation of LARC as a limitless ‘cure all’ risked ‘constructing an image of women who choose non- LARC methods as irresponsible, ignorant and incompetent with regards to contraceptive choice and maintenance or somehow wilfully complicit in raising their chances of unplanned pregnancy and the abortion rate’.
Kaye Wellings, Professor of Sexual and Reproductive Health Research at the London School of Hygiene and Tropical Medicine, draw on qualitative research with users and non-users of LARC. Among LARC users, Wellings presented some data on reasons for switching to LARC, and in the case of ‘stoppers’, their reasons for giving the method up; for never users, she presented data on the reasons that deter them from using LARC. Wellings noted that foremost among objections to LARC methods are unwanted side effects - weight gain, excessive or irregular bleeding, or loss of libido – and that myths abound about LARCs, which could be addressed to improve uptake.
Contraception: Will the Pill survive a century?
The discussion about LARCs was followed by a session looking at the history of the contraceptive pill, and its prospects for the future. Lara Marks, Senior Research Fellow at King’s College London and author of the influential book Sexual Chemistry: A history of the contraceptive pill, discussed how the pill has continued to be viewed as an icon of the sexual revolution of 1960s, generating interesting questions about its impact on society and the degree to which it liberated women and men. Her presentation explored the intense debates about the risks and benefits of the pill since its first introduction, noting that it became one of society’s first ‘lifestyle’ or ‘designer’ drugs of the twentieth century, which was very much pushed for by women.
A lively presentation by Christian Fiala, Medical Director of the Gynmed Clinic for Contraception and Abortion in Vienna and Salzburg, Austria, discussed the ways in which advances in contraception have always been framed by competing desires to control women’s decisions: even to the point where the results of pregnancy tests used to have to be given by a doctor, because of fears about women’s motivations for knowing whether they were pregnant. He critiqued the ongoing attachment to notions that methods of family planning should be as ‘natural’ as possible, given that nature would dictate that women had a dozen pregnancies over the course of their reproductive lives, and the whole point of modern contraception is to correct the imperfections of nature. The goal of nature is not necessarily the same as the goal of each individual human being, he argued. For example we try to have only a limited number of children in order to be able to raise them and help them to find their way in life in the best possible way, whereas nature just wants to make sure the species continues - individual suffering or happiness is not a factor.
‘Late’ abortions and fetal anomaly: Towards a woman-centred service
The final session of the ‘Pills in Practice’ conference discussed the issues involved in providing abortions in later gestations, and for reasons of fetal anomaly. Helen Statham of the Centre for Family Research at the University of Cambridge discussed her research into clinicians’ attitudes towards the ‘offer’ of termination for fetal abnormality in relation to particular diagnosed conditions. Statham noted that the decision to undergo a termination of pregnancy because a fetal abnormality has been diagnosed prenatally can only be made by parents once a termination has been offered, and that this offer may depend on potentially complex interactions between the nature of the abnormality; the gestational age at diagnosis; the law; the attitude of the diagnosing clinician; and public opinion.
Statham’s presentation discussed how this interaction can lead to different options being available to different women and couples who might be deemed to be in similar circumstances, and the implications this has for women and for service providers.
The presentation given by Stephen Robson, Professor of Fetal Medicine at Newcastle University, explored the gap between women’s choice of abortion method and the services that are offered to them, and emphasised the extent to which choice of surgical method is usually only available in independent sector clinics. In this regard, it is important to see the independent sector (which, in the case of organisations like BPAS and Marie Stopes International, provide abortions under contract from the NHS), as am integrated part of the abortion service as a whole.
Robson argued that services provided to women undergoing termination of pregnancy for fetal anomaly are often not ‘woman-centred’ insofar as they are often undertaken in a different unit to the one that provided the prenatal diagnosis; choice about method may be limited; and the karyotyping and follow-up may not be consistently offered. He discussed several specific aspects of termination of pregnancy, including the impact on psychological outcome of women’s ability to choose the method of termination; the impact of fetal anomaly and gestational age; and postmortem examination – for which it is often assumed that a medical induction is necessary, even though this is not always the case.
Ellie Lee, Director of the Centre for Parenting Culture Studies at the University of Kent, discussed the cultural context in which late abortion is provided. Although there is formal availability of abortion through to 24 weeks under some conditions, Lee argued, there are very different perceptions of ‘early’ and ‘late’ abortion, including among doctors. Central to differences in perception is the issue of the perception of the fetus - in general, the abortion issue has become increasingly ‘fetucised’, in that it has become focused more and more around the unborn child-to-be, rather than the needs of the pregnant woman.
Following this, Lee argued that even the acceptance of earlier abortions does not rely centrally or mainly on an idea about the importance of choice and moral autonomy for the woman - rather, it is as much about the idea that unwilling mothers will make not such good mothers, and as such reproduces some problematic themes that exist within wider parenting discourse. Lee concluded that what is needed in today’s context is creative thinking about how to encourage a commitment to the idea of choice.
The final presentation was given by Kate Guthrie, Clinical Director of the Hull and East Riding Sexual and Reproductive Healthcare Partnership, on the topic on training a new generation of abortion doctors. Guthrie noted that in the UK, training for late surgical abortion procedures is offered as an option rather than as a core part of obstetric training. She noted that an Abortion Care Study Day held by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2008 identified training as an issue, and her talk discussed problems and potential solutions to the problem.
The work of the newly-established British group Medical Students for Abortion Care has helped to raise awareness of the need for a new generation of abortion doctors, and in April it was announced that the US group Medical Students for Choice (MSFC) is to fund grants for up to 15 British and Irish trainees to take up intensive fortnight-long placements at a BPAS clinic.
2013 conference: Abortion, motherhood, and the medical profession
Closing the conference, Clare Murphy, BPAS director of External Affairs, noted BPAS’s commitment to an ongoing programme of discussions and debates about the future of fertility. Already in the diary is a conference to be held jointly by BPAS and the Sexuality and Sexual Health Section of the Royal Society of Medicine, on 12 June 2013, which will explore further issues to do with the abortion law, women’s experiences, and clinical practice.
In the meantime, Abortion Review will be publishing edited transcripts of the presentations from the ‘Pills in Practice’ conference, in downloadable pdf format. Watch this space for details.
For the full conference programme and speakers’ biographies, see the conference website here: www.futureofabortion.org
Watch the video of Ann Furedi’s opening speech on Politics.co.uk, here.
Women finding access to contraception ‘difficult’. Four in ten women who unintentionally became pregnant had problems getting appropriate contraception, a survey has found. Daily Telegraph, 11 May 2012