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Event: Developments and obstacles in abortion services
Jennie Bristow reports on a recent conference at London’s Royal Society of Medicine.
A solid, interesting programme covered some of the key ‘developments and obstacles’ in British abortion services, from the provision of Early Medical Abortion in a variety of settings to surgical techniques, to the wider issues of conscientious objection, misinformation and staff attitudes that surround the provision of abortion services.
Three sessions in the morning discussed Early Medical Abortion (EMA). Jeanette Flower, Lead Nurse for Worcestershire Pregnancy Advisory Service, gave a presentation based on her experience of setting up and running an EMA service in a community-based contraceptive clinic, in which she highlighted the nurse-led aspects of this clinic and outlined some of the benefits for women.
Dr Patricia Lohr, Medical Director of BPAS, followed by discussing the provision of an EMA service in General Practitioner (GP) services. Lohr noted that the UK abortion law requires that abortions be carried out in premises approved for the purpose by the Secretary of State for Health - therefore, gynaecologists and GPs cannot perform early medical and surgical procedures in office settings, as they do in some other countries.
However, BPAS does run four EMA services out of GP premises, including one in the Midlands that carries out over 400 early medical abortions a year. She clarified that these services are licensed by the Department of Health as independent sector abortion clinics in their own right but are located within GP premises. Lohr spoke about some of the disadvantages of this form of provision, compared to services offered in bpas’ own units, in that their clinics in GP premises have limited space and hours, and are not integrated with the GP practice.
The big advantage of providing services out of GP premises is that it allows for more local provision, which is important to women. But, Lohr stressed, operating ‘pop-up’ clinics out of GP surgeries is only possible because women go home after the administration of misoprostol: if they were required to stay on site until the expulsion of the pregnancy, even the limited flexibility of this service would be impossible to provide.
Dr Annely Kero, senior lecturer in the Department of Social Work at Umeå University in Sweden, gave an insightful presentation based on her research into women’s experiences, views and reactions about administering misoprostol at home. Roughly half of early medical abortions in Sweden are completed at home, and this research found that women and their partners generally appreciated the ability to choose this as empowering and important for their privacy and comfort.
Kero noted that, for many women in her study, the aspect of EMA that women experienced as the most emotionally charged was the taking on mifepristone on Day One, which is done in the clinic or hospital: this was the part of the abortion that women experienced in ‘existential terms’, as the death of the fetus. The waiting period between the two drugs (Day 2) was generally seen not to have ‘positive meaning’, and the expulsion of the pregnancy on Day 3 was generally accompanied by a sense of relief, and experienced with varying degrees of physical pain.
Thus, in contrast to the assumption that is often made - that the physical ‘miscarriage’ aspect of EMA is the hardest for women - Kero’s research indicated that, in many cases, it may be the first stage of the abortion pill process that is experienced as the most emotionally difficult. The pain and bleeding that women experienced on Day 3 were often considered by them to be better managed in the comfort of their homes than in a clinic or hospital, where this would have seemed like a more ‘dramatic act’; and women’s partners positively appreciated their role in being able to care for their partners through the ‘home abortion’.
The conference then moved to a discussion of surgical techniques. Dr Stephen Searle, Clinical Director of Sexual Health Services in Derbyshire, discussed the progress that has been made with Manual Vacuum Aspiration (MVA) since its introduction into the Chesterfield service 10 years ago. Searle emphasised that MVA should be offered more widely as a ‘quicker and less painful alternative’ to early medical abortion, and explained that in his service, women will be in the clinic for approximately half an hour, and that procedure itself takes about three minutes.
MVA also has the advantages of being an ‘inexpensive’ low-tech’ method of abortion, and Searle stressed the importance of perfecting the technique - there is ‘no need for maceration of the products of conception’.
Dr John Spencer, Senior Clinical Consultant at Marie Stopes International (MSI), presented the findings of a two-year audit carried out of MSI cases of Dilatation and Evacuation (D&E) at 19-23 weeks’ gestation. The key to MSI’s success with this method, stated Spencer, is achieving adequate cervical preparation, and he outlined the way techniques have been refined over the years to enable MSI to carry out these later surgical abortions as day-care procedures.
The MSI audit indicated the safety of D&E at later stages: of the 1,584 cases carried out over the audit period, seven clients were transferred to the local NHS hospital with complications, four of which required intervention. Spencer also noted that twice as many surgical abortions at 19-23 weeks are carried out in the NHS-funded independent sector (including MSI and bpas) than in NHS hospitals, confirming the relative lack of surgical provision for later abortions within the NHS itself.
Moving to a discussion of the wider ethical issues surrounding abortion provision, Dr Kelly Culwell, Senior Abortion Adviser at International Planned Parenthood Federation (IPPF) discussed the tensions involved when conscientious objection is invoked in reproductive healthcare: an issue better discussed using the more precise term Conscientious Refusal of Care (CRC). Culwell outlined the obligations that exist, both at the level of healthcare providers and nation states, to protect an individual’s right to object to direct participation in abortions on conscience grounds, but also to ensure that women can access the procedure where it is legal.
Culwell noted the ‘abuse’ of CRC that can take place where conscience grounds are cited illegitimately: for example, through institutions, such as Catholic hospitals, claiming a conscientious objection to particular reproductive healthcare treatments; and outlined the need to take steps to measure the ‘authenticity’ of conscientious objection. In resource-poor areas, she argued, conscientious objection should not be used as a ‘tool for limiting access’ to abortion, in situations where abortion is legal but there is no provider prepared to carry it out.
She concluded by citing some high-profile instances where CRC has come to the fore in relation to abortion, including the reaction to an article published in the British Medical Journal in 2010, where a junior doctor described her experience of being assigned repeated sessions in the weekly termination of pregnancy clinic in her hospital, despite being heavily pregnant. On querying the appropriateness of this decision, this doctor was reportedly told that was told that ‘as most of the other doctors had conscientiously objected I was the only junior doctor available for those weeks’. (1)
Dr Sam Rowlands, Honorary Associate Professor at the Institute of Clinical Medicine, Warwick Medical School and organiser of this conference at the RSM, discussed the key sources of ‘misinformation’ that are popularised in relation to abortion. He outlined five claims: that abortion poses a risk to a woman’s life, to her mental health, or to her future fertility, that it carries an increased risk of breast cancer, and the preoccupation with ‘fetal pain’, and briefly debunked these claims by using solid research.
The sources of such misinformation vary from websites to non-peer-reviewed journals, and are particularly troubling in relation to the biased or false information given directly to women by so-called ‘Crisis Pregnancy Centres’. Rowlands referred to a 2009 study by Joyce Arthur of such centres in a province of Canada as an example of how this misinformation process works through.
The final presentation of the conference was given by Dr Edna Astbury-Ward, counselling nurse and Visiting Research Fellow at Glyndwr University, North Wales. Astbury-Ward presented the findings of a very small qualitative study of staff working in abortion care, which flagged some interesting areas for future research.
The staff whom Astbury-Ward had interviewed were generally conscious of a sense of isolation from other medical colleagues brought about by working in abortion services. Some were highly motivated to work in abortion services; those who were not were more apt to voice pejorative attitudes about the women seeking abortion. Astbury-Ward indicated that ‘repeat’ abortions tended to provoke particularly negative emotions amongst staff, whereas women seeking abortion because of fetal abnormality would sometimes get more sympathetic treatment than other women.
Above all, Astury-Ward’s presentation indicated the benefits of having people working in abortion services who had a positive commitment to choice, and this led to an audience discussion about how one’s motivation to work in abortion services could be more widely popularised. Indeed, the sense of the acceptability of abortion services in today’s society, the skill with which procedures can now be carried out at all gestations, and the enduring need for access to women-centred services ran through the day’s discussions.
While there remain some major obstacles to the provision of excellent abortion care in the UK - notably, some of the more archaic constraints imposed by the interpretation of the 1967 Abortion Act - there have nonetheless been varied, rapid and significant developments in abortion services. The RSM conference provided an important platform for taking stock of this progress, and highlighting some exciting areas for further research and debate.
Abortion services: Developments and obstacles took place at the Royal Society of Medicine on Friday 15 April 2011. See the programme here.
(1) Should pregnant doctors work in termination of pregnancy clinics? By Megan Millward. BMJ 2010; 340:c867 (Published 17 February 2010) Email: doctormillward@gmail.com
(2) Exposing Crisis Pregnancy Centres in British Columbia: A Research Project for the Pro-Choice Action Network. By Joyce Arthur. January 2009
Source: http://www.abortionreview.org
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