Thursday, 26 June 2014

Young people and 'repeat abortion'

Thanks to a small grant from the European Society of Contraception and Reproductive Health we have been able to undertake a project looking into repeat unplanned conceptions amongst young people in London. This blog gives an overview of what we found out from our workshops with young people in Croydon.

Readers of this blog will probably already know that a third of women in Britain experience abortion. What you might not know is that over a third (37%) of those accessing abortion have already had one or more terminations. Recent statistics for England and Wales show that in 2013 27% of abortions to women aged 25 and under were ‘repeat abortions’. In Croydon, 50% of abortions (for all ages) were ‘repeat’ procedures.

The Telegraph claims the statistics show that women are having ‘lifestyle abortions’ and ‘using abortion as a contraceptive’. But what’s the real story? Why do some people have more than one abortion? Is it a problem? If so, when and why? We produced this document, Frequently Asked Questions about Repeat Abortion, to try to answer some of these questions and to offer recommendations for professionals supporting young people to prevent unwanted pregnancies. It’s free to download so please do have a read, and pass on to your colleagues. 

There are of course a number of factors which might contribute to someone experiencing one or more unplanned pregnancies – including failure rates of contraceptive methods. For example, the pill and the condom, the two most popular methods of contraception, come with actual-use failure rates of 8% and 15% respectively. In order to get young people’s input with the project we carried out workshops and focus groups in Croydon.  We talked about the fact that pills and condoms are the most common forms of contraception for young people and discussed some of the problems they might have in using these methods effectively:
“Pills - sometimes you don’t remember to take them. You have to take it at a certain time...so if you don’t actually remember to take it, you’re kind of unprotected.”
“As a female, you might not know how to put on a condom for instance, yeah I know it sounds really silly but let’s say you get to do the deed, you might not actually know how to put on a condom and stuff, and you kind of feel a bit stupid asking.”
“A lot of my friends didn’t (carry condoms) when we were younger, because no one wanted to be called a slag...you’ve been out with your boyfriend and you pull out a condom, he’s gonna think ‘Oi, you’re ready!’ Nah, he might not be thinking that, but in your mind you could possibly think it. 
He’s probably thinking, ‘Ah, I’m well up for this!’ But like it would be a bit embarrassing.”
Many of the young people formed opinions about contraceptive methods based on the experiences of their friends, often expressing an objection to LARC methods, seeing them as ‘invasive’:
“My friend’s got it (the implant) yeah, and I went with her and it’s horrible. It’s like this massive thing yeah, and to get it out she has to have an operation, she cuts it open, urgh, it’s horrible. Like, you can feel it.”
“I know it sounds silly, and you’re probably gonna laugh but it reminds me of something out of a movie, like an alien movie, you know like when they put things under your skin! The fact that you can feel it, in your day to day life, just, I don’t like that thought.”
“I went to the clinic with my friend, she got that (IUD) and the curtain was there - she was on that side and I was on this side, and I could hear her like ‘owwwww’!”
“And you have to be on your period to have it done don’t you, that’s what they said to my friend.  And I was like, dignity?! Come on!”
The young people (who were 16+) said that their school education had lacked details on the full range of contraceptive methods:
“Whenever you had any lessons at school it was always about condoms or the pill, it was never anything else about any other contraceptions.”
“When you’re at school, there’s not enough. All you hear about is the pill, not the implant or the injection, I never heard of that until a couple of years ago and I was like ‘what’s that?’. But then you are put off as well, by other people’s stories – of when they’ve put it in and you’re like, ‘Oh god, that doesn’t sound very nice’.”
These young people made various suggestions for improving knowledge about reproductive health and the range of contraceptive methods available:
“Make it less scary... if you see a picture like that (diagram of IUD), like they need to draw it to scale maybe! You know when you look at that, even though it’s small, in your mind, you’re gonna think, oh my god it’s massive...instead of drawings (you need) an actual picture of what it actually looks like. Cos you wouldn’t know what it looked like until you actually went there would you?”
“Maybe nurses do talks or something about how they put it in, ‘cause someone like me, could never do that ‘cause I’d just cry my eyes out. I’m really squeamish.” 
“I feel like there should be more talks within schools, about different types, like it is only condoms and the pill that are discussed.”
“Tell teenagers about contraception through videos, so they can just watch it – when people give me leaflets on the street I just throw them away, or just put it in my bag and it will stay in there for like a year! Whereas if, I don’t know, there was like pop up ads or something .”
“A video to show in schools, ok, these are the different types of contraception. These are the facts.”
So young people are telling us that they would like more practical demonstrations of contraceptive methods – we’ve certainly had positive reactions when using the FPA’s contraceptive display kit, which allows young people to see and touch different methods. There is also the suggestion that educators use more videos – and since we know young people respond to other people’s experiences, how’s about a UK version of these Bedsider videos? Someone fund us and we’ll do it!

For more information on young people and repeat unintended conceptions have a look at EFC's own research from 2007 and Hoggart and Phillips' 2010 research report.


Thursday, 12 June 2014

Abortion rate continues to drop in England and Wales

The latest statistics for abortion in England and Wales (2013) have been released today and can be viewed here on the Gov.UK website. Here's a summary.
For women resident in England and Wales, in 2013:
  • The total number of abortions was 185,331 
  • The abortion rate (for ages 15-44) was 15.9 per 1000 women, 0.8% lower than last year's abortion rate, and 4.7% lower than in 2003
  • The abortion rate was highest for women aged 22
  • The under-16 and under-18 abortion rates are both lower than last year, and than in 2003
  • 37% of women having an abortion had had one or more previous abortions
  • 53% of women having abortions had one or more previous pregnancies that resulted in a live birth or a still birth
  • 91% of abortions were carried out at under 13 weeks gestation
  • In 2013, there were 5,469 abortions for non-residents carried out in England and Wales. The 2013 total is the lowest in any year since 1969

So those are the numbers but what do they tell us?
Well, first of all, the abortion rate is the lowest it's been for 16 years, the 2013 stats show a continued decrease. The same is true for the rate of abortion for under 18s - this has gone down from 18.2 per 1000 women to 11.7 per 1000 women in the last ten years. This drop reflects the reduced rate of teenage conceptions in general and is likely a result of young people's increased access to contraception. The rate of women accessing abortion early on in pregnancy is a positive sign that most are able to have their pregnancy confirmed early and access abortion when it is safest.
When asked, people often assume abortion rates will be highest for teenagers, when in fact, the most common age to have an abortion was 22, and there was a slight increase in the abortion rate for women aged 25-29. Bpas suggests that that this may well reflect the increasing desire to have children later (the average age for first time motherhood in the UK is now over 28). Over half of women accessing abortion are already mothers.
In 2013, approximately 5500 abortions were performed in England and Wales for non-resident women. The majority of these women (67% and 15%) were from Ireland and Northern Ireland respectively. This shows a continuing decline in the numbers of non-resident women accessing abortion in England and Wales. The FPA suggests that this could be due to under-reporting, or women travelling to other countries for the procedure. We also suggested last year that these women may well be (illegally) finding abortion medication online, rather than travelling for the procedure, which can be very expensive.
We join the FPA in calling for Northern Irish women's right to free, safe, legal abortion in line with women in other parts of the UK, and with bpas that, "we should stop politicising abortion and accept that it is a standard part of women's healthcare."

Wednesday, 28 May 2014

Teaching about periods - Guest post from Chella Quint

Chella Quint is a performer, writer, and education researcher who uses her unique brand of comedy to engage the public in positive and enlightening conversations about menstruation. You can watch her TEDx Talk hereFor Menstrual Hygiene Day we've asked her to write a guest post and share top tips from her newly launched #PeriodPositive project which is all about challenging stigma connected to menstruation.

There are many sensitive topics within reproductive health and sex and relationships education.  Sometimes teachers and other educators are afraid to tackle these topics in case they ‘get it wrong’, and that’s understandable: making a mistake can be scary or embarrassing, or could even feel shameful. Challenging shame is one of the goals of Menstrual Hygiene Day, and it’s an issue I tackle frequently when challenging the messages in feminine hygiene product advertising.

There’s nothing to be ashamed of when talking about menstruation. It is a reproductive right for young people to understand their own fertility, and anyone can become a confident menstrual educator. 

Menstruation education should be:

  • Free, unbranded, objective, and inclusive of re-usables like menstrual cups and cloth pads
  • Consistent, accurate, up-to-date and peer-reviewed 
  • Supported more comprehensively by the National Curriculum, particularly in Science and PSHE
  • Aimed at different age groups, starting before puberty, and revisited regularly
  • Inclusive of different genders, cultures, abilities and sexualities

I've really enjoyed researching and developing this work both formally and informally, with schools, universities and through science engagement, and I'm continuing to create resources and test out lesson ideas. 

I always start by asking participants to plot their menstruation comfort zone on a spectrum line and on a bulls-eye chart: 



Here are some of the top tips from my research so far:
The full set of tips can be viewed here.

 Follow @Periodpositive for updates, and check back at www.periodpositive.com for more free resources soon.


Thursday, 8 May 2014

High Court ruling against free access to abortion for Northern Irish women

Today, a High Court judgement ruled that women from Northern Ireland are not entitled to access abortion free of charge through the NHS in England. 

Abortion is severely restricted in Northern Ireland and is only available where the pregnant woman’s life is in danger or where there is a risk of permanent and serious damage to her physical or mental health. This means that the vast majority of those seeking abortion in Northern Ireland will need to travel to access a safe, legal procedure. Currently, these women are required to pay for the procedure, which can range from approximately £400 to over £1000 for those at a later stage of pregnancy. The test case brought to the High Court by two women was rejected, meaning that the need for Northern Irish women to pay for abortion procedures carried out in England remains.

Northern Ireland is not covered by the current 1967 Abortion Act which applies in England, Scotland and Wales. The key legislation governing abortion in Northern Ireland comes from the Offences against the Person Act 1861. This means that women’s access to reproductive health care is managed according to a law which is over 150 years old and precedes the invention of the telephone and the light bulb.

The restrictive law in Northern Ireland does not prevent Northern Irish women having abortions, but it does make it more difficult. Those who can afford the private clinic fee and travel costs to England will be able to access a safe, legal abortion, but might have to significantly rearrange work and childcare to do so. Others may face delays in their attempts to raise a large sum of money in a short period of time. Overall, abortion is safe, but is safest the earlier in pregnancy it is performed, so delayed access means higher prices and also an increased chance of complications.

Those without access to such funds will be forced to continue an unwanted pregnancy (which again, is likely to have severe financial implications for someone who cannot afford an abortion), or they will resort to an illegal and potentially unsafe method of ending the pregnancy. Abortion Support Network is an organisation which helps women in Ireland and Northern Ireland to afford the cost of an abortion abroad. Mara Clarke, who runs the organisation, details some of the desperate measures people have taken to try to end their pregnancies:

“We have mothers calling us, telling us that their 18-year-old daughter drank a bottle of floor cleaner after she was raped at her own birthday party. We hear about women taking whole packets of birth control and washing it down with vodka.”

Others unable to travel will buy abortion medication online through sites such as Women on Web – however, if they do, they risk life imprisonment for ‘procuring (their) own miscarriage’.

The latest statistics from England and Wales show that in 2012 905 women travelled from Northern Ireland to access abortion. Many more will have travelled elsewhere or bought illegal abortion medication to end their pregnancies. Clearly, strict abortion laws do not stop abortions from happening, but can make them less safe by causing delay and restricting access. Abortion for Northern Irish women is largely a matter of economic resource. As Mara Clarke puts it, “women with money have options, women without money have babies”.

As a young people’s project we're particularly concerned about young women’s access to reproductive healthcare. In 2012, 43% of abortions in England and Wales for Northern Irish residents were for those under 25. Young women are less likely to have the resources necessary to travel and pay for a private abortion. A pregnant teenager seeking an abortion in Northern Ireland may suffer from stigma and lack of support, as well as financial limitations. 

The young woman who presented a test case to the High Court was just 15 when she became pregnant and travelled to Manchester for an abortion. Her mother paid £600 for the procedure, some of which was covered by the Abortion Support Network, and described the process of raising the funds as ‘harrowing’. Not all young women will have the support of their families. We believe that the abortion law in Northern Ireland should be brought into line with the rest of the UK, so that all women, especially young women, are able to access the full range of reproductive healthcare they need, which includes abortion.


Friday, 2 May 2014

Conscientious objection obstructs women’s health … it’s not brain surgery

Blogpost by Lisa Hallgarten

It doesn't take a brain surgeon to work out that you can’t be a brain surgeon if you don’t believe in brain surgery. Nor does it take a rocket scientist or even a person of average intelligence to work out that a doctor who is not willing to prescribe the full range of contraceptive methods should not have a qualification that implies that they are able and willing to do so. The Faculty of Sexual and Reproductive Healthcare (FSRH) which provides a diploma in sexual and reproductive health, has recently updated its guidelines to confirm that doctors and nurses who have a ‘conscientious objection’ to prescribing hormonal contraception - including emergency contraception – and fitting women with IUDs and IUSs will not be able to complete the whole syllabus that is required in order to receive its diploma.

This seems uncontroversial. No woman should go to a certified doctor with a specialist qualification to discuss contraception, only to discover that her doctor will not prescribe or fit some of the available methods for reasons of personal conscience. It would be worse still for a woman seeking emergency contraception, because those who seek the right to conscientiously object do not support any method of emergency contraception. In this situation time is of the essence: if a woman wants to take Levonelle it is most effective in the first 24 hours following unprotected sex, EllaOne must be taken within five days and an IUD fitted within the same time-frame. No woman should have to scrabble about trying to find an alternative doctor who will provide her with this last ditch chance to prevent an unwanted pregnancy. Nor should any woman be preached at about why the only moral thing to do in this situation is to cross her fingers and hope for the best. You would think that even those who support a doctor’s right to conscientiously object must agree with this, but apparently not. The Christian Medical Fellowship (CMF) objects to the updated guidance because, ‘it bars pro-life doctors from specialising in sexual and reproductive health and also makes it much more difficult for non specialists to get jobs in family planning or reproductive health’.

The CMF seems to be asking for something over and above the right to conscientiously object. It seems to be asking for the right for anti-choice doctors to be certified so that they can advertise their specialism in family planning and attract women seeking contraception, with the full intention of refusing access to the full range of family planning methods.  This is not about passively opting out, this is obstruction. Likewise, the case of the two Scottish midwives who insist that they can use conscientious objection to opt out of even supervisory and management duties in relation to staff carrying out abortions.  Their appeal against an original judgement which refused them this right, on the basis that it would jeopardise abortion provision in their hospital, was funded by anti-choice organisation SPUC. This kind of extension by stealth of the right to conscientiously object is addressed in a new paper, ‘Dishonourable disobedience – Why refusal to treat in reproductive healthcare is not conscientious objection’. The authors, Canadian abortion rights advocate, Joyce Arthur, and Austrian obstetrician Christian Fiala question the moral basis for conscientious objection and challenge its interpretation and implementation by anti-choice doctors and anti-choice institutions. It is the latest salvo in a pro-choice fightback against the once uncontested concept of conscientious objection, and crucial reading for anyone who still believes that it is a benign practice which is simply about the quiet expression of personal belief.

Other useful articles on conscientious objection personal, and institutional:



Tuesday, 1 April 2014

Intimate Partner Violence, Pregnancy and Abortion

The World Health Organisation defines Intimate Partner Violence (IPV) as “one of the most common forms of violence against women and includes physical, sexual, and emotional abuse and controlling behaviours by an intimate partner”. IPV has been shown to increase during pregnancy. Women’s Aid states that 30% of IPV starts during pregnancy and that between four and nine women out of every 100 are abused during their pregnancies and/or after having given birth. Women’s Aid identifies IPV as a prime cause of miscarriage, still-birth and of maternal deaths following childbirth.

One form of IPV is termed ‘reproductive coercion’ – where abuse relating to contraception or pregnancy decision-making is exercised by a woman’s partner. For example, the abuser may sabotage contraception, refuse to use it, or pressurise a partner into continuing or ending a pregnancy against their wishes. Perhaps unsurprisingly, a recent study found an association between IPV (naming rape and sexual assault, contraceptive sabotage and pregnancy coercion as examples) and termination of pregnancy. The study found that women in violent relationships were three times more likely to conceal an abortion from their partner as women in non-violent relationships and that “women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help”. What this tells us is that pregnancy support services need to be attuned to the risk factors for IPV and to be able to provide signposting and support where required. Domestic violence support services in turn, need to be equipped to provide accurate information on pregnancy choices and impartial support with pregnancy decision-making.

We were concerned to see that information about IPV and pregnancy is being misrepresented by anti-abortion organisation LIFE, in its recent ‘Finding Hope’ campaign. In a glossy animation LIFE claims that “the association between abortion and violence towards women is strong”. LIFE claims that one in four women seeking abortion are “victims of domestic violence” and “at least one in every four women seeking abortion, therefore, (is) not doing so freely but from a position of fear.” LIFE makes a causal relationship between IPV and abortion which is simply not in the data, implies that abortion itself is a form of violence, and states that “women who have abortions can become more self-destructive, and remain in or seek out abusive relationships as a form of self-punishment.” It is highly offensive to suggest that women have abortions, or remain in violent relationships as a form of ‘self-punishment’. It is also inaccurate to extrapolate this data to claim that a quarter of women seeking abortion do so out of ‘fear’.

It is not surprising that a large proportion of women who have abortions have also, at some point, experienced IPV. Both are very common within a lifetime. A third of women have an abortion. A quarter of women experience IPV. It is therefore inevitable that a significant number of those accessing abortion services will have also experienced IPV. What we know about IPV increasing during pregnancy, and about reproductive coercion as a form of IPV, means that there is of course a link between IPV, unplanned or unwanted pregnancy and therefore abortion, but this link is not one of simple causation as the LIFE Finding Hope campaign implies.

LIFE’s suggestion that “no one even asks them (pregnant women) if they are ok...let alone, why do you want an abortion...not even the health professionals tasked with caring for them” is particularly misleading. The Finding Hope campaign claims to, “draw attention to abortion providers' conveyor-belt service and their failure to adequately support women vulnerable to abuse”, the implication being that women seeking abortion are not assessed, supported or fully consenting to the procedure. In fact, bpas, a leading abortion provider and charity, takes a ‘routine enquiry’ approach to domestic abuse, which means staff routinely ask women about safety in their relationship. All staff are trained on domestic abuse issues and bpas provides information in formats which are accessible to a range of people and signposts to relevant agencies. The Royal College of Obstetricians and Gynaecologists advises medical professionals to work to identify those at risk of IPV and provide appropriate support.

LIFE’s campaign culminates in a fundraising appeal for its helpline service. LIFE, which campaigns against legal (and therefore safe) abortion does not appear to be promoting genuine advocacy on domestic violence issues, but rather conflates abortion with abuse in order to argue against abortion. We are particularly concerned that LIFE’s ‘counselling’ services have been shown to be misleading and biased, for example, one LIFE counsellor falsely claimed that abortion leads to an increased risk of breast cancer. Giving women false information in an attempt to influence their decision about a pregnancy is unethical. The narrative provided by LIFE, that women seek abortion only out of ‘fear’ or coercion, is simply not accurate, and negates women’s agency when it comes to making sometimes difficult choices about pregnancy. The connections between IPV and abortion are perhaps best looked at through the reproductive justice framework, which recognises that sometimes our 'choices' are restricted by factors such as economic status, race, class, location and so on. This useful factsheet from the National Women's Law Center, 'If You Really Care About Preventing Domestic and Sexual Violence, You Should Care About Reproductive Justice' makes clear the need to improve material conditions surrounding pregnancy and IPV and points out that restrictions on access to contraception and abortion services will only further constrain a person's ability to exercise bodily autonomy.

*****There is a confidential 24-hour National Domestic Violence Helpline on 0808 2000 247. This helpline is free and run in partnership by Refuge and Women's Aid who can provide information and support to those experiencing domestic violence. ******

Slide from LIFE's 'Finding Hope' animation which places abortion within a 'cycle of abuse'.


Wednesday, 26 March 2014

NICE guidance on young people and access to contraceptive services

Today, NICE released evidence-based guidance entitled ‘Contraceptive services with a focus on young people up to the age of 25’, which calls for improved access to contraception for young people. 

The guidance sets out various actions which it suggests will improve young people’s access to contraception, and thus decrease unplanned pregnancies amongst under 25s. As you may know, the teenage pregnancy rate in England and Wales is currently the lowest it’s been since 1969, but still remains one of the highest in Western Europe.

The guidance provides practical suggestions for improving young people’s access to sexual health services such as ensuring that services are:

Accessible (have flexible opening hours and accessible materials for those with learning difficulties, or for whom English is a second language)
Comprehensive (give information on the full range of contraceptive options, including the insertion of an IUD as a method of emergency contraception)
Practical (youth-focused services based in schools and colleges, where young people can access them easily)
Non-judgemental (staff should be trained and supported to offer impartial information)

We were glad to see that NICE specifically mentions the importance of access to contraception following pregnancy, encouraging professionals to "dispel the myth that there is no need for contraception after an abortion and explain that women are fertile immediately following an abortion." We have long been concerned that the myth that abortion causes infertility, often touted by anti-abortion groups which visit schools, may have an impact on a young woman’s access to contraception following an abortion.

The media reaction to the guidance has been interesting, with some outlets focusing on NICE’s suggestion that emergency hormonal contraception (EHC) be available in advance of sexual activity (rather than just obtained following unprotected intercourse).

The guidance states that "the evidence shows that advance provision of oral emergency contraception does not encourage risky sexual behaviour among young people. Evidence also shows that women who have emergency contraception in advance are more likely to use it, and to use it sooner after unprotected sex. Having emergency contraception on hand does not affect the use of other kinds of contraception."

Certainly, we have heard anecdotally of young women’s difficulty in obtaining the morning after pill. Some pharmacists refuse to give EHC to younger women, or attempt to charge them (at around £20 this can be too much for many teenagers). Some young people living in rural areas might struggle to get hold of EHC, especially in the first 24 hours after unprotected sex, when it is most effective. It makes sense to improve access to EHC for those who need it, to ensure it can be taken when needed, as quickly as possible.

However, some newspapers seem to think that there is a danger young women will ‘stockpile’ EHC. The Telegraph opens with:

“Teenage girls will be able to stock up on the morning-after pill under new NHS guidance which will allow young women to pre-order the drugs, despite Government fears the move will increase promiscuity.”

An interesting concept. These young women, who are seen as too feckless to access contraception before having sex, are organised enough to plan to ‘stockpile’ EHC in advance of having sex. Which is it to be, lazy and incompetent or cunning and prepared?! EHC is a form of contraception, which young people already have free access to. NICE is simply stating that it might be helpful for some young women (particularly those who live in rural areas, perhaps without their own transport) to be able to access EHC in advance, in case they ever need it.

We’re glad to see such sensible, evidence-based guidance being issued, we only wish the media could resist scare-mongering around young people and contraception, and that access to sexual and reproductive health could be rid of such stigma.