Thursday 30 May 2013

Henry Morgentaler and abortion in Canada

This week, Dr Henry Morgentaler died at the age of 90. Not many people here in the UK have heard his name but he is an extremely important figure in the abortion rights movement.

Born in Poland, Morgentaler’s Jewish family were sent to Auschwitz in 1944 – his mother and sister died there. Morgentaler survived both Auschwitz and Dachau and eventually settled in Canada where he graduated from the University of Montreal as a medical practitioner. When contraception was legalised in 1969 he began to specialise in ‘family planning’ and was one of the first Canadian doctors to provide IUDs and contraceptive pills to the unmarried.

On behalf of the Canadian Humanist group to which he belonged, Morgentaler spoke at a House of Commons meeting in 1967, stating his belief in the importance of safe, legal abortion for women. This appearance led to him being inundated with requests to perform abortions (at the time the procedure was illegal, except to save the woman’s life) which at first he refused, through fear of prosecution. However, through his medical practice he encountered a number of women who had suffered from botched illegal abortions and saw, first hand, the effect this lack of access had on their health and lives. In 1968 Morgentaler performed his first abortion at his private clinic, for the 18 year old daughter of a friend. He said:
 “I decided to break the law to provide a necessary medical service because women were dying at the hands of butchers and incompetent quacks, and there was no one there to help them...The law was barbarous, cruel and unjust. I had been in a concentration camp, and I knew what suffering was. If I can ease suffering, I feel perfectly justified in doing so.”
In 1969, the law changed to allow abortion, but only in hospitals, and where a woman’s request had been approved by a committee. However, the majority of hospitals did not have such a committee, and many did not meet, so women in these areas were still suffering from a lack of legal access to abortion. Morgentaler’s abortions remained illegal under this law, and he risked life imprisonment as well as physical attacks and death threats in order to challenge the law and provide safe, legal abortions to the women he saw in his clinics.

When Morgentaler was put on trial in the 1970s his lawyer argued the ‘defence of necessity’ – that as a doctor, Morgentaler’s responsibility was to safeguard the health and life of his patient, overriding legal restrictions which might conflict with this. Despite being acquitted by a jury, he was sentenced to 18 months in prison and underwent a number of trials and appeals to challenge the existing law. Eventually it was the public support for legal abortion, and for Morgentaler’s campaigning and actions which led to abortion becoming legal in 1988. Public juries repeatedly acquitted Morgentaler and polls found that a vast majority of Canadians believed abortion should be a decision made by a woman and her doctor. The Supreme Court ruling in 1988 essentially removed all criminal restrictions on abortion, leaving it to be governed by Canada's laws concerning medical practice (as with other medical procedures).

The Chief Justice in this case said at the time:
"Forcing a woman, by threat of criminal sanction, to carry a fetus to term unless she meets certain criteria unrelated to her own priorities and aspirations, is a profound interference with a woman's body and thus a violation of her security of the person."
Canada remains one of the few places in the world where there are no legal restrictions on abortion. Many worry that a lack of such restrictions will lead to an increase in abortions, but this is evidently not the case:
In Canada, the teenage birth and abortion rate is 27 per 1000 women between the ages of 15-19 versus 61.2 per 1000 women in the United States.

The abortion rate among all women of reproductive age (15-44) in Canada is 14.1 per 1000 versus 20 per 1000 in the United States. (Stats from Dr Jen Gunter).

Friday 24 May 2013

What are the factors most strongly associated with teenage pregnancy?

The Centre for Analysis of Youth Transitions released a report this week which links teenage conception data to the education records of all girls attending state schools in England. It looks at associations between pregnancy and individual and social factors such as absenteeism and deprivation. As it’s a 53 page document we’ve put together a brief summary of the findings here.

This Department for Education funded report compares information on teenage pregnancy (number of conceptions, conceptions leading to maternity or abortion) to data from English schools (pupils who are eligible for free school meals, who are frequently absent, who have special educational needs etc). For those of us working in this area, the key findings are not all that surprising:
“Teenage conception and maternity rates are higher in deprived areas”
“Girls who attend higher performing schools are less likely to conceive, and more likely to have an abortion if they do conceive”
We know already that teenage pregnancy relates to particular social factors, and that young women in deprived areas are more likely to get pregnant, and when pregnant more likely to continue the pregnancy and become young parents. A 2004 study looking at national variation in teenage abortion and motherhood found that “abortion proportions and social deprivation are strongly correlated”, and that young women’s socio-economic backgrounds are a strong influence on their decision to continue or end a pregnancy. The researchers interviewed young people who had had abortions/given birth and their responses give a fascinating insight into the inevitability of particular pregnancy choices for young women:
“There was no question of me keeping it because I knew I was going to go to university...I didn’t want a baby...I’d had a good education and I had a career path to go down, it was all laid out for me.”
This latest piece of research found that eligibility for free school meals and being persistently absent from school were the factors most strongly associated with teenage pregnancy and the decision to continue with a pregnancy. Those who are eligible for free school meals are more than twice as likely to conceive as those who are not. This is important information for anyone working in sexual and reproductive health and education services, and clearly there is a need to think about making these services truly accessible to young people outside of school, through outreach and non-educational settings.

Although we know there are important individual and social factors to consider when planning work which aims to prevent unwanted pregnancies, one finding from the study bears highlighting:
“Teenage conceptions occur in all social groups, areas and types of school. Similarly, teenage conceptions occur in rich and poor areas and in schools with high and low levels of attainment: no characteristic provides complete “protection” from teenage conception”
In other words, there are no young people who don’t need (and deserve) evidence-based and accessible information and support with pregnancy and pregnancy decision-making. In an ideal world, this information would be available to young people in and out of school, regardless of their ethnic and social background.

Wednesday 22 May 2013

Bipolar and pregnant

Thank you to guest blogger Zoe for allowing us to share her thoughts on the recently reported case of a woman who was granted legal access to abortion following a challenge to her ability to consent. This is cross-posted on Zoe's own blog 'The Fementalists'.

Today a woman, identified only as “SB”, won her High Court battle to be allowed to have an abortion. This fact may seem strange to many readers as since the Abortion Act was passed in 1967 legal abortion has been mostly accessible to women in England, Scotland, and Wales . However, the woman at the centre of this case has bipolar disorder and it was argued by doctors and her family that she lacked mental capacity to consent to the procedure. Lawyers representing the health authority told the judge “she is believed to lack the capacity to make a decision regarding the termination of her pregnancy due to her mental disorder.'' Fortunately, the judge disagreed with this assessment, stating that it would be "a total affront" to her autonomy to decide that she was unable to have an abortion.

I have been following this case closely as I also have bipolar disorder and as a young woman with a male partner I worry a lot about the possibility of an unplanned pregnancy, to say nothing of worrying about what my future holds in terms of planned pregnancy. It was stated in the Court that the woman in this case had stopped taking her medication and thus relapsed, culminating with her being detained under the Mental Health Act. However, many medications for bipolar are not suitable to take when pregnant as they can cause birth defects such as neural tube defects, heart defects, and developmental delay or neurobehavioural problems. Thus many people have to stop taking their medication if they wish to continue with their pregnancies. This is believed to be what happened in the “SB” case. While this may seem like a relatively minor thing, the consequences of this can be devastating. Rates of relapse into bipolar mania and psychosis are estimated at 50% to 75% respectively and WebMD states that Pregnant women or new mothers with bipolar disorder have seven times the risk of hospital admissions than pregnant women who do not have bipolar disorder.” So clearly the risk of being detained under the Mental Health Act also greatly increases during pregnancy because of the additional problems caused by stopping medication.

For me, this represents the nightmare scenario. Finding myself pregnant with a wanted foetus only to stop my medication, relapse and be detained under the Mental Health Act, and to then decide that for my own health I would like a termination and be denied it because it is argued that I lacked capacity. It is truly a terrifying prospect to find yourself unable to control your own body because you have a mental illness. Much more needs to be done to provide perinatal care for women with severe and enduring mental illness to ensure that a situation like this never arises again. Fortunately in this case the judge has made the right decision and SB is expected to have an abortion in the following days. Arguably, this situation should never have arisen in the first place.

Friday 17 May 2013

The effect of homophobia and transphobia on universal access to reproductive health

Today is IDAHO, otherwise known as ‘The International Day Against Homophobia and Transphobia’. We decided to blog about the relevance of reproductive rights to people of all (or no) genders and sexualities, and some of the problems those who identify as LGBT* can face in accessing sexual and reproductive health services and relevant information.

Why are reproductive rights important for people of all genders and sexualities?

When I tell people I work on a project which educates young people on pregnancy options they’ve asked if we only visit girls’ schools, and have expressed skepticism at the usefulness of covering this topic at a workshop for LGBT* youth. At EFC we believe everyone has a stake in understanding how reproduction works, and how people can be supported to make decisions about sex, contraception and pregnancy that are right for them. Here are some thoughts on why this is a subject which breaks though cisgendered/heterosexual ‘norms’:

-    Most people with a womb have at least the capability to get pregnant at some point in their lives. Even those who don’t choose to have vaginal intercourse can become pregnant, for example through sperm accidentally coming into contact with the vagina through non-penetrative intercourse, or as a result of rape.
-    Research has shown that young people who identify as gay, lesbian and bisexual may in fact be at a higher risk of unplanned pregnancy than their heterosexual peers. Stigma surrounding sexuality can lead some young people to ‘prove’ heterosexuality through sexual contact with a partner of the ‘opposite’ sex.
-    As Thomas Beatie has shown with his high-profile pregnancies, trans men and transmasculine people can and do become pregnant and may require specific information on this process.
-    Those who are unable to conceive in what is often seen as the ‘natural’ or ‘traditional’ way, may decide to access services which allow them to become pregnant (e.g. IVF) or to become parents through other means (adoption, fostering and surrogacy).
-    People who cannot themselves become pregnant may have close contact with those who do, whether it be a partner, family member or friend.
-    Many of the individuals and groups which seek to restrict abortion access also argue against LGBT* rights – for example, anti-choice group SPUC is currently running a campaign against equal marriage and has claimed that ‘making homosexual couples the legal parents of children is not in the best interests of children’.

What are some of the barriers for people who are LGBT* in accessing reproductive health services?

Outright stigma, and homo/trans/biphobia is a clear barrier for equal access to services. The stories gathered by #transdocfail showed systematically poor treatment of trans* people in health services, likely to be reflected in consultations relating to sexual and reproductive health. Media outrage and sensationalised headlines relating to LGBT* parenting are unlikely to make those who identify as such eager to access support and services. And as well as stigma, there may be legal restrictions to reproductive rights – the Swedish government has only just vowed to remove a statute which requires all transgender people to be sterilised in order to have their gender recognised legally.

Beyond direct objection to equal reproductive rights, there is also often a lack of tailored resources and information for those who are lesbian, gay, bisexual and/or transgender. In our own work we are trying to address this by using language that is inclusive, and thinking of ways to address gaps in resource provision, making links between the reproductive rights and LGBT* rights movements where possible. Thankfully, some progress is being made – we’ve listed some useful resources below but please do add your own comments and suggestions.

Useful resources

Wednesday 1 May 2013

What might the ‘Protection of Life During Pregnancy Bill’ mean for Irish women seeking abortion?

The Irish government has produced a bill which if passed, will, according to Prime Minister Enda Kenny, ‘clarify the circumstances’ in which medical practitioners can intervene to save a woman’s life by providing abortion. Kenny has stated that the new bill “would continue within the law to assert the restrictions on abortion that have applied in Ireland and which will apply in future”. In other words, it does not seek to change Irish law on abortion, which states that abortion is restricted only to cases where the pregnant woman’s life is in danger. Following the recent death of Savita Halappanavar in Galway there has been a demand for clarification on the circumstances in which doctors can legally provide life-saving treatment. Kenny claims that if the bill goes through it will “at last bring certainty to pregnant women and legal clarity to medical personnel who work within the system”.

So what does the bill actually say?

The bill is carefully worded so as not to present decision making around abortion as privileging the rights of the woman over the rights of the developing pregnancy. Suggested provisions are purely about saving a woman’s life in emergency situations and all efforts must be made to protect the ‘unborn child’ (as the pregnancy is referred to) wherever possible:

“Essentially the decision to be reached is not so much a balancing of the competing rights rather, it is a clinical assessment as to whether the mother's life, as opposed to her health, is threatened by a real and substantial risk that can only be averted by a termination of pregnancy.”

Some provision is made for those women who claim to be suicidal in the face of having to continue an unwanted pregnancy. It is proposed that in such cases, three doctors are to examine the woman and must reach a unanimous decision on the threat to her life. If the three doctors do not agree, the woman may appeal to another three consultants, meaning that her case could potentially be reviewed by six separate medical professionals.

What are people saying about the bill?

Members of the government claim that the bill would provide much needed clarity to enable doctors to work within the very restrictive Irish abortion law. However, there have been criticisms from both pro-choice and anti-abortion campaigners.

Some anti-abortion campaigners have evidenced concerns about the law being ‘relaxed’ with access to abortion expanded. Former Irish Prime Minister John Bruton said the idea that “a simple threat of suicide would make right something that would otherwise be wrong is a really dangerous principle”. And in a recent televised debate, a Fine Gael politician was asked if potentially fatal health risks are an 'acceptable risk' in pregnancy, or whether they are grounds for abortion in some cases. He responded: "But sure we’re all going to end up dead anyway." This begs the question of why he’s against abortion, and indeed whether he thinks medical care is redundant for all people whose lives may be in danger or just pregnant women.

Many pro-choice campaigners have taken issue with the ‘suicide clause’ in the bill. A spokesperson from the Centre for Reproductive Rights calls it ‘outrageous and paternalistic’ and goes on to criticise Irish abortion law more generally as being an “absolute violation of international human rights norms on women's right to health and dignity. It's totally off track with the rest of Europe."

In summation, the bill is not yet passed, and if it does go through both houses of Irish parliament, it will not make any changes to the law itself. Even with these amendments the thousands of Irish women who travel to the UK (and elsewhere) to access abortion would still need to do so. Arguably it might make provision for rare cases in which the woman's life is threatened but this will still sit within a legal framework which threatens to prosecute doctors whose actions are seen as being outside of these restrictions.

To follow the debate we suggest checking out the Irish ‘Doctors For Choice’ campaign which will provide regular updates.

The Protection of Life During Pregnancy Bill can be viewed in full here.