TC
5th June 2007, 13:46
I think its really messed up how conservative people on revleft have gotten on abortion rights. I think these three articles from Spiked-Online are quite good (as Spiked-Online usually takes an uncompromising stance for civil liberties regardless of its faults in other areas) and would encourage people weak on abortion rights to read them, especially the two Ellie Lee articles.
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Ellie Lee
Abortion: better ‘late’ than never
A contributor to a controversial study outlines the reasons why women need access to abortion - even five months after becoming pregnant.
Though the issue of ‘late’ abortion is hotly debated, there has been surprisingly little research done on a crucial question: why do women seek abortions so late in pregnancy? A recently published paper has gone a long way to filling this gap by asking women who had abortions between 13 and 24 weeks into pregnancy to explain their reasons for doing so. The research has been widely reported and commented on, particularly in the UK. Here, Dr Ellie Lee, a member of the research team, discusses the context for the research, and summarises some of its findings.
As articles about abortion on spiked have noted, the abortion controversy has shifted more and more towards a focus on ‘late’ abortion. Ultrasound pictures of ‘walking’ fetuses, media reporting of ‘miracle babies’ born early at 22 weeks but surviving, and horror stories of ‘botched abortions’ where fetuses briefly show signs of life after late abortion procedures, have often set the terms of recent public debate.
There has always been a host of myths and misconceptions about abortion, but these debates have added new ones to the list. These include misunderstandings about science, and what it tells us about fetal development (see The wrong debate about abortion rights by Ellie Lee). They also include confusions about the circumstances and experiences of women who have late abortions.
All women who have abortions are the subject of widespread misunderstanding. Ignorance about their circumstances is reflected in negativity about abortion by commentators who seem unable to comprehend why a woman ever becomes pregnant when she does not plan to. This approach shows a profound lack of knowledge of contraceptive methods and their failure rates, and a lack of insight into the nature of sex and relationships (1). As a result, unfortunately, women who have abortions rarely appear in the public debate as what they are: ordinary women, from all walks of life, who most often seek abortion because they happen to have become pregnant accidentally through contraceptive failure. Instead, they are usually presented as possibly deserving victims (if they have got pregnant from rape or incest, for example) or they are imagined to be ‘selfish career women’ or ‘slappers’ who ‘use abortion as contraception’.
When it comes to late abortion, ignorance about the women concerned and the nature of their experiences seems even greater. This is reflected in the fact that late abortion is often discussed without reference to women at all, as if the ‘walking fetuses’ or ‘born alive fetuses’ were never inside a woman, who in turn played no significant part in their gestation or consideration of their future. If the women concerned are brought into the picture, it is often with incomprehension – ‘how could they possibly end up five months into a pregnancy and not have sorted themselves out sooner?’
Consequently, discussion of late abortion has tended to produce more heat than light. This is a problem arguably compounded by the notion, popularised by some who are pro-choice, that the ‘problem’ of late abortion could be made to ‘go away’ if early abortion were made easier to access. This argument tends to add to the perception that late abortion is inherently problematic and purely a byproduct of the way the abortion service is run (see We still need abortion as early as possible, as late as necessary, by Ellie Lee).
In this context, I was delighted to have been recently involved in a research study that sought to examine the real reasons why women have abortions at 13 to 24 weeks of pregnancy. In all, 883 women participated in the research. The study has raised a raft of interesting points, including the following:
* A major reason for delay in the pathway to abortion is due to women not realising that they are pregnant. This was the case for many women in our study because they normally had irregular periods and so did not consider missing periods to be a sign of pregnancy. Many also reported what appeared to them to be ‘continuing periods’ (probably light bleeding that did not progress further to lead to miscarriage). And for many women, the fact they were using contraception meant the possibility of falling pregnant was simply not on their minds. These were major reasons why half of the women questioned were already more than 13 weeks pregnant by the time they requested an abortion.
* After requesting an abortion, delays were partly service-related. Delay at this stage was caused by difficulties in getting further appointments, and by confusion amongst doctors first approached (mostly general practitioners) about where a procedure should take place. These sorts of confusions may be related to the fact that the abortion service in many areas has become complex. Primary Care Organisations, which are responsible for commissioning health services for the local area, are likely to purchase abortion services from a range of providers. National Health Service (NHS) hospitals often look after women having abortions in early pregnancy, but in many areas later abortions are increasingly provided by independent abortion providers such as the British Pregnancy Advisory Service (bpas). Unless measures have been taken to make sure relevant health professionals know how to refer women speedily to the right place, confusions about where women need to go to obtain their abortion lead to delays.
* Forty-one per cent of women in the study said they were unsure about having an abortion and therefore it took some time to make up their minds. Many reported that various aspects of relationships with their partners and/or parents (especially for younger women) played a role in delays in their decision-making about whether to have an abortion. Twenty-three per cent overall said their relationship with their partners had broken down or changed following confirmation of the pregnancy. This indicates that, for some women, the decision to have an abortion is also a decision about whether to become a parent or have another child, and is dependent on broader changes and complications in their personal lives.
Overall, these findings can provide the basis for a more useful discussion of abortion than we have had here in Britain lately. They show, first, that there are ‘service-related’ reasons for delayed abortions, and therefore that practical measures should be taken to help women obtain abortion as early as possible. In particular, if effort was put into minimising delays at the point of referral for abortion, then gains could be made. If this very real, concrete problem leading to later abortion became a talking point, it would make more difference to the incidence of late abortion than any amount of discussion about whether a fetus can or cannot smile.
The findings also show that there are many ‘women-related’ reasons for late abortion. These are more nuanced and a policy solution is less obvious. Contraception fails women, pregnancy symptoms are misidentified as such, and women’s relationships are sometimes unpredictable. These sorts of reasons indicate that late abortion is not simply an abstract moral problem, but a reflection of everyday, real life.
In the end, a key point to press is that women who have abortions at 13 to 24 weeks’ gestation are just like the rest of us. How many of us can honestly say we cannot imagine misreading what is happening to our body when we are pregnant, especially if we have never been pregnant before? How many of us cannot put ourselves in the shoes of the woman who finds that her partner does not react in the way she expected to the news that she is pregnant? How many of us who have children can say, hand on heart, that any and every future pregnancy, whatever our circumstances, would always be unequivocally welcome?
To seek to understand the choice for abortion is to seek to understand the nature of everyday, normal problems and experiences for women. Let us hope that more people engage with these problems in the future.
Ellie Lee is a lecturer in social policy at the University of Kent.
http://www.spiked-online.com/index.php?/site/article/3130/
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Ann Furedi
Abortion: some messages can’t be massaged
It's time to ditch the spin and tell the truth about why women have abortions, and what would happen if they were denied them.
Communications and ‘messaging’ play a larger part in politics and social policy than at any time in history. In the UK, as in the US, it seems that policymakers spend more time trying to work out how to ‘sell’ initiatives to the public than they do assessing how effective these initiatives would be if they were adopted. ‘Will it win votes/support?’ seems more important than, ‘Is it true?’ or ‘Will it work?’. Naturally, this affects – one might say ‘frames’ – the abortion discourse on both sides of the pond.
Pro-choice advocates know we must move on from the slogans of the past because social concerns have changed. The advance of reproductive technologies and fetal medicine has stimulated an interest in the development of life before birth that did not exist 30 years ago. In the 1970s, abortion was seen as an issue affecting a woman (‘Our bodies, our lives, our right to decide’). Now public opinion is increasingly concerned with the fetus (‘Does it feel pain? Does it have rights?’). In the 1970s, women’s equality was an ambition to be fought for; now many believe it has been achieved. The language of the ‘right to choose’, which once seemed central to women’s freedom, now makes many people uncomfortable.
We must address this discomfort. To do this we have to engage with contemporary concerns, and we can all agree that research that examines what alienates people from pro-choice perspectives is vital to do this. However, there is a danger that we become so concerned with ‘branding’ that we lose sight of what we stand for. We do ourselves no favours – and much fault – when, in the hope of framing abortion to make it acceptable to the widest constituency, we forget essential truths. One of these truths is that access to abortion underpins, and is essential to, women’s equality.
Rights and abortion
It seems unfashionably fundamentalist to defend the notion that women should have a ‘right’ to abortion. It does not play well with the public, who sometimes misunderstand what it means.
This is not surprising. Today, we talk imprecisely about the ‘right’ to many things – the right to be happy, the right to be stress-free, the right to have our views respected. But this promiscuous use of the term degrades the concept of a ‘right’. For those of us who emerged from a progressive, humanist tradition, ‘rights’ designate the requirements for participation in bourgeois democratic society. Rights are what are required to make people equal.
Thirty years ago, this specific concept of rights was shared by democrats and those concerned with social justice. The right to abortion and contraception was a basic tenet of the women’s liberation movement in its early years, along with the right to equal pay and equal job opportunities, because activists understood that women needed control over their fertility to play an equal role in public life. When you deny me a means to end my unwanted pregnancy, you deny me the opportunity to participate in society in the way that my brother or husband can. Better nurseries and better financial support can mitigate some of the consequences of motherhood – but nothing can mitigate the impact of pregnancy itself, which is why women need the means to end it.
This has not changed: it is as true in 2006 as it was in 1976. Contraception has improved, but is still fallible. Abortion is a necessary back-up to birth control for any society that is committed to equality of opportunity for women. The discourse of women’s equality may have changed, but its fundamental prerequisites have not.
There is also another way in which the right to abortion must be non-negotiable. When we are denied the right to end pregnancy we lose our right to bodily autonomy; a fundamental human right central to Western civilisation. The ethics of modern medical practice are built on the notion that each of us has the right to refuse to compromise our bodily integrity. You might find it morally reprehensible for me to refuse to give up a kidney that could be transplanted to save the life of my son, but there is no law to force me to do it. In the UK, the same is true of birth decisions. In refusing a Caesarean section delivery, I may condemn my unborn baby to certain death, but I commit no crime in doing so.
No doctor can force me to accept a medical intervention against my consent, unless I am mentally incompetent. The law forces us to draw a distinction between what is legal and what we regard as morally right and wrong. We accept this because we accept that a society able to compel un-consented medical intervention in the interests of someone else is a greater social evil than an occasional unpalatable individual choice.
This unfashionable privileging of ‘rights’ is not divorced from the more acceptable stress on responsibility. Surely it is right, if not ‘a right’, for women to be allowed to make their own moral choices concerning their pregnancy. The decision must be made by someone: why should it not be made by the person whose life is most connected to it? Ronald Dworkin argues compellingly that part of our belief in human dignity rests on people having ‘the moral right and moral responsibility to confront the most fundamental questions about the meaning and value of their own lives for themselves’ (1). Each of us must be answerable to our own conscience and conviction; this, he argues is part of what makes us human. To take away our responsibility for our moral decisions is to take away our humanity.
This is somewhat inconvenient to those trying to construct a popular and populist argument for legal abortion. It implies we must allow people to make decisions that we believe are wrong – because it would be more wrong for us to deny them the capacity to do that. As Dworkin argues eloquently: ‘Tolerance is the cost we must pay for our adventure in liberty.’
This statement of principle is unlikely to score well in focus groups or to ‘gain traction’ even among many who would regard themselves as pro-choice. I am not suggesting that we insist on a principled defence of liberty during our future struggles to keep abortion legal. But we should be mindful of why, in the past, we argued for abortion as a right. It was not because we were less sensitive, less educated, less tactical, and less subtle than now; but because we needed to explain why abortion mattered. We still do, even if we need to do it in a different way in a social climate less inclined to adventure in liberty.
The limits to the ‘public health’ argument
Of course, we can be pragmatic – we don’t have to talk in the language of rights. The UK provides an interesting example of where abortion access has been expanded and improved by a political administration that situates abortion, not as a right, but as a public health concern.
In the UK, the abortion discourse has been almost silent as to ‘rights’. Since abortion was legalised in the 1960s, it has been treated as a matter of public health. Abortion access has been accepted as a way to address social problems of deprivation and exclusion, to reduce the number of ‘unfit parents’ and ‘problem families’. The framing of abortion in a personal and public health context has made it difficult to oppose. When abortion is seen as a health matter, to argue against abortion is to argue against a doctor’s decision about what is best for a patient.
In Britain today, there is a social consensus that children should be planned and wanted and that parents should be responsible. Such is the consensus that abortion is necessary that in 2005 the UK government committed itself officially to an assessment of the consequences of making abortion unlawful. In a cost analysis of potential legislation that would make abortion illegal except in cases of risk to life or rape, the benefit of the enactment of such a Bill was documented as: ‘Provides a social-moral benefit to members of the public that are pro-life and disagree with the principal of abortion.’ The cost of enactment was documented as: ‘£750million a year net financial costs, high risk of up to 15 deaths a year, 15,000 extra teenage mothers a year, 12,000 children a year neglected/abused.’ The parliamentary under-secretary of state for public health signed that she believed this represented a fair comparison of the costs and benefits.
The public health arguments for abortion have the potential to unite social liberals and conservatives. Even those who think abortion is abhorrent draw back from the practical consequences of making it unlawful. In the UK there is a broad consensus that abortion is a ‘lesser evil’, a wrong that is sometimes right.
The opportunism of leading on public health is understandable, even forgivable, providing we are mindful of the rights issues that stand silently in the shadows. We must remain aware of them lest the public health benefits of abortion cause conservatives to become over-zealous as to abortion’s role in reducing the costs of unwanted births to ‘problem’ families. Just as we must tolerate those deciding to have abortions in circumstances that we may think are wrong, so our defence of the right to bodily autonomy compels us to defend a woman’s right to continue her pregnancy. Acknowledgement and respect for this is what separates us from the Neo-Malthusians who see abortion as a social solution to poverty and disadvantage.
Abortion’s moral dimension
It may be that the arguments around public health are where we can establish the greatest consensus on abortion’s acceptability. However, any such consensus will be partial because the moral dimension will remain contentious. This is inevitable and insurmountable. There can be no moral consensus that includes those who believe that the destruction of human life in the womb is wrong and those who believe it is not. It may be possible to establish a pragmatic consensus among those who are prepared to discuss which abortions are less wrong than others, but attempts to establish foundations for a broader moral consensus degenerate into glibness.
Take journalist Will Saletan’s suggestion, in his much-discussed New York Times leader, that to galvanise public sentiment we should adopt the principle that, ‘Abortion is bad, and the ideal number of abortions is zero’. It is difficult to see how this engages the discussion in a meaningful way at all, given that no one argues: ‘Abortion is good, and the ideal number of abortions is a million.’
Even those of us who believe that abortion is ‘a right’ understand that women do not exercise their right to abortion in the same way they exercise their right to vote. We can acknowledge that access to abortion is a social good while acknowledging that it’s a bad experience for an individual woman to have one. Whatever the socio-political meaning of abortion, for an individual woman, it is her private solution to her individual problem.
For sure, we can win agreement that it would be good if abortion didn’t exist. But this is about as meaningful as a consensus that the ideal number of poor people is zero. As Bob Geldof and Bono recently discovered, it is easy to get people to say they want to ‘make poverty history’; who did they think would argue that we want to keep poverty contemporary? It was agreement on how to achieve it that proved impossible. So it is with abortion; the devil, some would say, is in the detail. The public knows this, even if communications consultants pretend they don’t – which is why, often, the arguments that ‘play well’ in focus groups play less well outside them.
The morality of abortion cannot be resolved in the abstract. Each individual abortion takes place within its own complex set of circumstances. To understand abortion we need to understand its place in women’s lives.
It may be that we can best build support for legal abortion by putting the spin to one side and telling the whole truth: the truth about what abortion is, the truth about why women have them, and the truth about what it means for women when bodily autonomy is denied. Maintaining support for legal abortion is not about messaging – it is far more complex and important than that. To defend abortion we must win arguments in favour of tolerance and encourage an aspiration for liberty. To win the arguments, first we must have them.
Ann Furedi is CEO of bpas (the British Pregnancy Advisory Service). Email her at [email protected] This essay was originally published in the winter edition of Conscience, the journal of the American charity Catholics for a Free Choice, which serves as a voice for Catholics who believe that the Catholic tradition supports a woman’s moral and legal right to choose.
(1) Life’s Dominion: An Argument About Abortion and Euthanasia, Ronald Dworkin, HarperCollins 1993
http://www.spiked-online.com/index.php?/site/article/2108/
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Ellie Lee
Abort these lazy anti-choice arguments
How a tentative study from New Zealand about abortion and mental health was turned into cast-iron evidence that abortion makes women mad.
‘Abortion exposes women to higher risk of depression.’ So stated a headline in The Times (London) on 27 October. In the same paper, under the headline ‘Risks of abortion’, there was a letter signed by 15 doctors raising concerns about the impact of abortion on women’s mental health, which triggered the news story.
The letter claimed that recently published research provides definitive evidence of a causal link between abortion and the development of psychiatric conditions. On this basis, argue the signatories, abortion providers should change their methods, and women seeking abortion should be informed that terminating pregnancy puts them at risk of suffering from mental ill-health.
This latest story tells us little about any real relationship between a woman’s reproductive issues and her state of mind, but a lot about the state of the abortion debate in general and the mindsets of those opposed to abortion.
The study referenced by the letter-signatories was published in the Journal of Child Psychology and Psychiatry under the title: ‘Abortion in young women and subsequent mental health.’ It concluded that, ‘[Our] findings suggest that abortion in young women may be associated with increased risks of mental health problems.’ For those who take research seriously, even this single line suggests the researchers reached very different conclusions to those presented in The Times.
The study was firstly of young women: it considered the experiences of women aged 15 to 25. The researchers make no claims about women in general; their interest lies in the experience of adolescents and young adults. (It should also be noted that the young women studied grew up in a particular area of New Zealand, which may also be significant for the relevance of the results to other societies.)
But the most important word in the researchers’ conclusion is ‘may’ – ‘abortion in young women may be associated with increased risks of mental health problems’. Where the signatories to The Times letter make strong assertions and argue for policy changes, the original journal article contains important riders. These are:
-- Confounding factors that this study may not have accounted for. The authors note that their findings may not have taken into account factors other than abortion which might account for the observed association between abortion and particular states of mind;
-- Under-reporting of abortion in the sample. This is a well-recognised problem with research about abortion. The authors of this latest study note there was a statistically significant difference between the rate of abortion in the sample and that among the population in general;
-- Contextual factors associated with abortion-seeking to which the study could not be sensitive. For example, the authors note that, ‘It is clear the decision to seek (or not seek) an abortion following pregnancy is likely to involve a complex process’, and consequently ‘it could be proposed that our results reflect the effects of unwanted pregnancy on mental health rather than the effects of abortion per se on mental health’.
This last point, about the effects of unwanted pregnancy, is especially important. Three groups of women were compared in this study: women who said they had an abortion, against women who had not experienced a pregnancy and women who had continued a pregnancy to term. It was against this background that an association was made between abortion and poorer mental health. Yet the study was conducted in a context where abortion is legal, and relatively freely available. So it must be taken into account that, among these three groups of women, it will likely have been those whose pregnancy was truly and consistently unwanted who went on to have an abortion.
In other words, it may be the fact that their pregnancy was unwanted and possibly seen as a burden, rather than the fact they had an abortion, which contributed to certain states of mind.
The most valid comparator group to women who have an abortion is not women who have not experienced pregnancy or women who have given birth because they want to, but rather women with unwanted pregnancies who are denied abortion and who then give birth. When these two groups of women – those with unwanted pregnancies who opt for abortion and those with unwanted pregnancies who are denied abortion – are compared, we can at least be pretty certain that the context of pregnancy is similar for both, and that what is being compared is the effects of the resolution of the pregnancy (birth or abortion) on the women’s state of mind.
Yet this latest study did not include a group of women who were denied abortion, which is understandable, given the relatively free abortion laws in New Zealand. Other research has shown that lack of choice in continuing an unwanted pregnancy has a stronger association with poor mental health than abortion.
The authors of this latest study are right to be tentative in their conclusions. They are correct to conclude that ‘the issue of whether or not abortion has harmful effects on mental health remains to be fully resolved’, and to call for more research into the area.
In taking this approach they also reflect what seems to be a consensus in this area of abortion research. Academic research about the psychological effects of abortion is widely recognised as a complicated enterprise. As noted by American psychologist Henry David, a prolific writer on this subject, designing research that can make definitive statements about the psychological effects of abortion, and other reproductive events, is a complex task – far more complex than research on abortion and physical health, where it can be clearly stated that abortion is a relatively safe medical procedure.
For this reason, the British Royal College of Obstetricians and Gynaecologists (RCOG) wisely takes stock every now and then of the range of published studies on the issue, before drawing up its evidence-based guidelines for British abortion providers. In its leaflet for women considering abortion, the RCOG says: ‘How you react will depend on the circumstances of your abortion, the reasons for having it and on how comfortable you feel about your decision. You may feel relieved or sad, or a mixture of both.’ It also notes that: ‘Some studies suggest that women who have had an abortion may be more likely to have psychiatric illness or to self-harm than other women who give birth or are of a similar age. However, there is no evidence that these problems are actually caused by the abortion; they are often a continuation of problems a woman has experienced before.’
This reads as a balanced approach, taking careful account of the available evidence. It tells women and their loved ones about the general conclusions of published, peer-reviewed evidence. This is in stark contrast to the line taken by the letter-signers to The Times, who called for British medical authorities to change the way things are. On the basis of one study from New Zealand of women aged under 25, which actually makes only tentative claims and recommends further research, the signatories claim that ‘doctors [in Britain] have a duty to advise about the long-term psychological consequences of abortion’.
How did they come to this conclusion? The emphasis on the ‘risks of abortion’ and their alleged implications for abortion practice arises, not from any balanced consideration and debate about well-designed academic research, but from political attitudes to abortion.
Today, those who are hostile to abortion find it difficult to frame their arguments in moral terms. For a range of reasons, very few will agree these days that abortion is simply ‘wrong’, and so there is little support for attempts to moralise against abortion. At the same time, the language of risk increasingly provides a medicalised vocabulary in which anti-abortion arguments can be made. In effect, we have the ‘medicalisation’ of anti-abortion arguments through the use of the language of risk. Those of us who support a woman’s right to choose should challenge this new anti-abortion focus, and demand a higher standard in discussions of research and evidence.
Dr Ellie Lee is author of Abortion, Motherhood and Mental Health: Medicalising Reproduction in the US and Britain, published by AldineTransaction, and coordinator of the Pro-Choice Forum.
References:
‘Doctors’ letter sparks debate over abortion and mental health’, Abortion Review, 30 October 2006
‘The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7’, RCOG September 2004
‘Abortion in young women and subsequent mental health’. Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry. 2006 Jan; 47(1): 16-24.
http://www.spiked-online.com/index.php?/site/article/2047/
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Ellie Lee
Abortion: better ‘late’ than never
A contributor to a controversial study outlines the reasons why women need access to abortion - even five months after becoming pregnant.
Though the issue of ‘late’ abortion is hotly debated, there has been surprisingly little research done on a crucial question: why do women seek abortions so late in pregnancy? A recently published paper has gone a long way to filling this gap by asking women who had abortions between 13 and 24 weeks into pregnancy to explain their reasons for doing so. The research has been widely reported and commented on, particularly in the UK. Here, Dr Ellie Lee, a member of the research team, discusses the context for the research, and summarises some of its findings.
As articles about abortion on spiked have noted, the abortion controversy has shifted more and more towards a focus on ‘late’ abortion. Ultrasound pictures of ‘walking’ fetuses, media reporting of ‘miracle babies’ born early at 22 weeks but surviving, and horror stories of ‘botched abortions’ where fetuses briefly show signs of life after late abortion procedures, have often set the terms of recent public debate.
There has always been a host of myths and misconceptions about abortion, but these debates have added new ones to the list. These include misunderstandings about science, and what it tells us about fetal development (see The wrong debate about abortion rights by Ellie Lee). They also include confusions about the circumstances and experiences of women who have late abortions.
All women who have abortions are the subject of widespread misunderstanding. Ignorance about their circumstances is reflected in negativity about abortion by commentators who seem unable to comprehend why a woman ever becomes pregnant when she does not plan to. This approach shows a profound lack of knowledge of contraceptive methods and their failure rates, and a lack of insight into the nature of sex and relationships (1). As a result, unfortunately, women who have abortions rarely appear in the public debate as what they are: ordinary women, from all walks of life, who most often seek abortion because they happen to have become pregnant accidentally through contraceptive failure. Instead, they are usually presented as possibly deserving victims (if they have got pregnant from rape or incest, for example) or they are imagined to be ‘selfish career women’ or ‘slappers’ who ‘use abortion as contraception’.
When it comes to late abortion, ignorance about the women concerned and the nature of their experiences seems even greater. This is reflected in the fact that late abortion is often discussed without reference to women at all, as if the ‘walking fetuses’ or ‘born alive fetuses’ were never inside a woman, who in turn played no significant part in their gestation or consideration of their future. If the women concerned are brought into the picture, it is often with incomprehension – ‘how could they possibly end up five months into a pregnancy and not have sorted themselves out sooner?’
Consequently, discussion of late abortion has tended to produce more heat than light. This is a problem arguably compounded by the notion, popularised by some who are pro-choice, that the ‘problem’ of late abortion could be made to ‘go away’ if early abortion were made easier to access. This argument tends to add to the perception that late abortion is inherently problematic and purely a byproduct of the way the abortion service is run (see We still need abortion as early as possible, as late as necessary, by Ellie Lee).
In this context, I was delighted to have been recently involved in a research study that sought to examine the real reasons why women have abortions at 13 to 24 weeks of pregnancy. In all, 883 women participated in the research. The study has raised a raft of interesting points, including the following:
* A major reason for delay in the pathway to abortion is due to women not realising that they are pregnant. This was the case for many women in our study because they normally had irregular periods and so did not consider missing periods to be a sign of pregnancy. Many also reported what appeared to them to be ‘continuing periods’ (probably light bleeding that did not progress further to lead to miscarriage). And for many women, the fact they were using contraception meant the possibility of falling pregnant was simply not on their minds. These were major reasons why half of the women questioned were already more than 13 weeks pregnant by the time they requested an abortion.
* After requesting an abortion, delays were partly service-related. Delay at this stage was caused by difficulties in getting further appointments, and by confusion amongst doctors first approached (mostly general practitioners) about where a procedure should take place. These sorts of confusions may be related to the fact that the abortion service in many areas has become complex. Primary Care Organisations, which are responsible for commissioning health services for the local area, are likely to purchase abortion services from a range of providers. National Health Service (NHS) hospitals often look after women having abortions in early pregnancy, but in many areas later abortions are increasingly provided by independent abortion providers such as the British Pregnancy Advisory Service (bpas). Unless measures have been taken to make sure relevant health professionals know how to refer women speedily to the right place, confusions about where women need to go to obtain their abortion lead to delays.
* Forty-one per cent of women in the study said they were unsure about having an abortion and therefore it took some time to make up their minds. Many reported that various aspects of relationships with their partners and/or parents (especially for younger women) played a role in delays in their decision-making about whether to have an abortion. Twenty-three per cent overall said their relationship with their partners had broken down or changed following confirmation of the pregnancy. This indicates that, for some women, the decision to have an abortion is also a decision about whether to become a parent or have another child, and is dependent on broader changes and complications in their personal lives.
Overall, these findings can provide the basis for a more useful discussion of abortion than we have had here in Britain lately. They show, first, that there are ‘service-related’ reasons for delayed abortions, and therefore that practical measures should be taken to help women obtain abortion as early as possible. In particular, if effort was put into minimising delays at the point of referral for abortion, then gains could be made. If this very real, concrete problem leading to later abortion became a talking point, it would make more difference to the incidence of late abortion than any amount of discussion about whether a fetus can or cannot smile.
The findings also show that there are many ‘women-related’ reasons for late abortion. These are more nuanced and a policy solution is less obvious. Contraception fails women, pregnancy symptoms are misidentified as such, and women’s relationships are sometimes unpredictable. These sorts of reasons indicate that late abortion is not simply an abstract moral problem, but a reflection of everyday, real life.
In the end, a key point to press is that women who have abortions at 13 to 24 weeks’ gestation are just like the rest of us. How many of us can honestly say we cannot imagine misreading what is happening to our body when we are pregnant, especially if we have never been pregnant before? How many of us cannot put ourselves in the shoes of the woman who finds that her partner does not react in the way she expected to the news that she is pregnant? How many of us who have children can say, hand on heart, that any and every future pregnancy, whatever our circumstances, would always be unequivocally welcome?
To seek to understand the choice for abortion is to seek to understand the nature of everyday, normal problems and experiences for women. Let us hope that more people engage with these problems in the future.
Ellie Lee is a lecturer in social policy at the University of Kent.
http://www.spiked-online.com/index.php?/site/article/3130/
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Ann Furedi
Abortion: some messages can’t be massaged
It's time to ditch the spin and tell the truth about why women have abortions, and what would happen if they were denied them.
Communications and ‘messaging’ play a larger part in politics and social policy than at any time in history. In the UK, as in the US, it seems that policymakers spend more time trying to work out how to ‘sell’ initiatives to the public than they do assessing how effective these initiatives would be if they were adopted. ‘Will it win votes/support?’ seems more important than, ‘Is it true?’ or ‘Will it work?’. Naturally, this affects – one might say ‘frames’ – the abortion discourse on both sides of the pond.
Pro-choice advocates know we must move on from the slogans of the past because social concerns have changed. The advance of reproductive technologies and fetal medicine has stimulated an interest in the development of life before birth that did not exist 30 years ago. In the 1970s, abortion was seen as an issue affecting a woman (‘Our bodies, our lives, our right to decide’). Now public opinion is increasingly concerned with the fetus (‘Does it feel pain? Does it have rights?’). In the 1970s, women’s equality was an ambition to be fought for; now many believe it has been achieved. The language of the ‘right to choose’, which once seemed central to women’s freedom, now makes many people uncomfortable.
We must address this discomfort. To do this we have to engage with contemporary concerns, and we can all agree that research that examines what alienates people from pro-choice perspectives is vital to do this. However, there is a danger that we become so concerned with ‘branding’ that we lose sight of what we stand for. We do ourselves no favours – and much fault – when, in the hope of framing abortion to make it acceptable to the widest constituency, we forget essential truths. One of these truths is that access to abortion underpins, and is essential to, women’s equality.
Rights and abortion
It seems unfashionably fundamentalist to defend the notion that women should have a ‘right’ to abortion. It does not play well with the public, who sometimes misunderstand what it means.
This is not surprising. Today, we talk imprecisely about the ‘right’ to many things – the right to be happy, the right to be stress-free, the right to have our views respected. But this promiscuous use of the term degrades the concept of a ‘right’. For those of us who emerged from a progressive, humanist tradition, ‘rights’ designate the requirements for participation in bourgeois democratic society. Rights are what are required to make people equal.
Thirty years ago, this specific concept of rights was shared by democrats and those concerned with social justice. The right to abortion and contraception was a basic tenet of the women’s liberation movement in its early years, along with the right to equal pay and equal job opportunities, because activists understood that women needed control over their fertility to play an equal role in public life. When you deny me a means to end my unwanted pregnancy, you deny me the opportunity to participate in society in the way that my brother or husband can. Better nurseries and better financial support can mitigate some of the consequences of motherhood – but nothing can mitigate the impact of pregnancy itself, which is why women need the means to end it.
This has not changed: it is as true in 2006 as it was in 1976. Contraception has improved, but is still fallible. Abortion is a necessary back-up to birth control for any society that is committed to equality of opportunity for women. The discourse of women’s equality may have changed, but its fundamental prerequisites have not.
There is also another way in which the right to abortion must be non-negotiable. When we are denied the right to end pregnancy we lose our right to bodily autonomy; a fundamental human right central to Western civilisation. The ethics of modern medical practice are built on the notion that each of us has the right to refuse to compromise our bodily integrity. You might find it morally reprehensible for me to refuse to give up a kidney that could be transplanted to save the life of my son, but there is no law to force me to do it. In the UK, the same is true of birth decisions. In refusing a Caesarean section delivery, I may condemn my unborn baby to certain death, but I commit no crime in doing so.
No doctor can force me to accept a medical intervention against my consent, unless I am mentally incompetent. The law forces us to draw a distinction between what is legal and what we regard as morally right and wrong. We accept this because we accept that a society able to compel un-consented medical intervention in the interests of someone else is a greater social evil than an occasional unpalatable individual choice.
This unfashionable privileging of ‘rights’ is not divorced from the more acceptable stress on responsibility. Surely it is right, if not ‘a right’, for women to be allowed to make their own moral choices concerning their pregnancy. The decision must be made by someone: why should it not be made by the person whose life is most connected to it? Ronald Dworkin argues compellingly that part of our belief in human dignity rests on people having ‘the moral right and moral responsibility to confront the most fundamental questions about the meaning and value of their own lives for themselves’ (1). Each of us must be answerable to our own conscience and conviction; this, he argues is part of what makes us human. To take away our responsibility for our moral decisions is to take away our humanity.
This is somewhat inconvenient to those trying to construct a popular and populist argument for legal abortion. It implies we must allow people to make decisions that we believe are wrong – because it would be more wrong for us to deny them the capacity to do that. As Dworkin argues eloquently: ‘Tolerance is the cost we must pay for our adventure in liberty.’
This statement of principle is unlikely to score well in focus groups or to ‘gain traction’ even among many who would regard themselves as pro-choice. I am not suggesting that we insist on a principled defence of liberty during our future struggles to keep abortion legal. But we should be mindful of why, in the past, we argued for abortion as a right. It was not because we were less sensitive, less educated, less tactical, and less subtle than now; but because we needed to explain why abortion mattered. We still do, even if we need to do it in a different way in a social climate less inclined to adventure in liberty.
The limits to the ‘public health’ argument
Of course, we can be pragmatic – we don’t have to talk in the language of rights. The UK provides an interesting example of where abortion access has been expanded and improved by a political administration that situates abortion, not as a right, but as a public health concern.
In the UK, the abortion discourse has been almost silent as to ‘rights’. Since abortion was legalised in the 1960s, it has been treated as a matter of public health. Abortion access has been accepted as a way to address social problems of deprivation and exclusion, to reduce the number of ‘unfit parents’ and ‘problem families’. The framing of abortion in a personal and public health context has made it difficult to oppose. When abortion is seen as a health matter, to argue against abortion is to argue against a doctor’s decision about what is best for a patient.
In Britain today, there is a social consensus that children should be planned and wanted and that parents should be responsible. Such is the consensus that abortion is necessary that in 2005 the UK government committed itself officially to an assessment of the consequences of making abortion unlawful. In a cost analysis of potential legislation that would make abortion illegal except in cases of risk to life or rape, the benefit of the enactment of such a Bill was documented as: ‘Provides a social-moral benefit to members of the public that are pro-life and disagree with the principal of abortion.’ The cost of enactment was documented as: ‘£750million a year net financial costs, high risk of up to 15 deaths a year, 15,000 extra teenage mothers a year, 12,000 children a year neglected/abused.’ The parliamentary under-secretary of state for public health signed that she believed this represented a fair comparison of the costs and benefits.
The public health arguments for abortion have the potential to unite social liberals and conservatives. Even those who think abortion is abhorrent draw back from the practical consequences of making it unlawful. In the UK there is a broad consensus that abortion is a ‘lesser evil’, a wrong that is sometimes right.
The opportunism of leading on public health is understandable, even forgivable, providing we are mindful of the rights issues that stand silently in the shadows. We must remain aware of them lest the public health benefits of abortion cause conservatives to become over-zealous as to abortion’s role in reducing the costs of unwanted births to ‘problem’ families. Just as we must tolerate those deciding to have abortions in circumstances that we may think are wrong, so our defence of the right to bodily autonomy compels us to defend a woman’s right to continue her pregnancy. Acknowledgement and respect for this is what separates us from the Neo-Malthusians who see abortion as a social solution to poverty and disadvantage.
Abortion’s moral dimension
It may be that the arguments around public health are where we can establish the greatest consensus on abortion’s acceptability. However, any such consensus will be partial because the moral dimension will remain contentious. This is inevitable and insurmountable. There can be no moral consensus that includes those who believe that the destruction of human life in the womb is wrong and those who believe it is not. It may be possible to establish a pragmatic consensus among those who are prepared to discuss which abortions are less wrong than others, but attempts to establish foundations for a broader moral consensus degenerate into glibness.
Take journalist Will Saletan’s suggestion, in his much-discussed New York Times leader, that to galvanise public sentiment we should adopt the principle that, ‘Abortion is bad, and the ideal number of abortions is zero’. It is difficult to see how this engages the discussion in a meaningful way at all, given that no one argues: ‘Abortion is good, and the ideal number of abortions is a million.’
Even those of us who believe that abortion is ‘a right’ understand that women do not exercise their right to abortion in the same way they exercise their right to vote. We can acknowledge that access to abortion is a social good while acknowledging that it’s a bad experience for an individual woman to have one. Whatever the socio-political meaning of abortion, for an individual woman, it is her private solution to her individual problem.
For sure, we can win agreement that it would be good if abortion didn’t exist. But this is about as meaningful as a consensus that the ideal number of poor people is zero. As Bob Geldof and Bono recently discovered, it is easy to get people to say they want to ‘make poverty history’; who did they think would argue that we want to keep poverty contemporary? It was agreement on how to achieve it that proved impossible. So it is with abortion; the devil, some would say, is in the detail. The public knows this, even if communications consultants pretend they don’t – which is why, often, the arguments that ‘play well’ in focus groups play less well outside them.
The morality of abortion cannot be resolved in the abstract. Each individual abortion takes place within its own complex set of circumstances. To understand abortion we need to understand its place in women’s lives.
It may be that we can best build support for legal abortion by putting the spin to one side and telling the whole truth: the truth about what abortion is, the truth about why women have them, and the truth about what it means for women when bodily autonomy is denied. Maintaining support for legal abortion is not about messaging – it is far more complex and important than that. To defend abortion we must win arguments in favour of tolerance and encourage an aspiration for liberty. To win the arguments, first we must have them.
Ann Furedi is CEO of bpas (the British Pregnancy Advisory Service). Email her at [email protected] This essay was originally published in the winter edition of Conscience, the journal of the American charity Catholics for a Free Choice, which serves as a voice for Catholics who believe that the Catholic tradition supports a woman’s moral and legal right to choose.
(1) Life’s Dominion: An Argument About Abortion and Euthanasia, Ronald Dworkin, HarperCollins 1993
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Ellie Lee
Abort these lazy anti-choice arguments
How a tentative study from New Zealand about abortion and mental health was turned into cast-iron evidence that abortion makes women mad.
‘Abortion exposes women to higher risk of depression.’ So stated a headline in The Times (London) on 27 October. In the same paper, under the headline ‘Risks of abortion’, there was a letter signed by 15 doctors raising concerns about the impact of abortion on women’s mental health, which triggered the news story.
The letter claimed that recently published research provides definitive evidence of a causal link between abortion and the development of psychiatric conditions. On this basis, argue the signatories, abortion providers should change their methods, and women seeking abortion should be informed that terminating pregnancy puts them at risk of suffering from mental ill-health.
This latest story tells us little about any real relationship between a woman’s reproductive issues and her state of mind, but a lot about the state of the abortion debate in general and the mindsets of those opposed to abortion.
The study referenced by the letter-signatories was published in the Journal of Child Psychology and Psychiatry under the title: ‘Abortion in young women and subsequent mental health.’ It concluded that, ‘[Our] findings suggest that abortion in young women may be associated with increased risks of mental health problems.’ For those who take research seriously, even this single line suggests the researchers reached very different conclusions to those presented in The Times.
The study was firstly of young women: it considered the experiences of women aged 15 to 25. The researchers make no claims about women in general; their interest lies in the experience of adolescents and young adults. (It should also be noted that the young women studied grew up in a particular area of New Zealand, which may also be significant for the relevance of the results to other societies.)
But the most important word in the researchers’ conclusion is ‘may’ – ‘abortion in young women may be associated with increased risks of mental health problems’. Where the signatories to The Times letter make strong assertions and argue for policy changes, the original journal article contains important riders. These are:
-- Confounding factors that this study may not have accounted for. The authors note that their findings may not have taken into account factors other than abortion which might account for the observed association between abortion and particular states of mind;
-- Under-reporting of abortion in the sample. This is a well-recognised problem with research about abortion. The authors of this latest study note there was a statistically significant difference between the rate of abortion in the sample and that among the population in general;
-- Contextual factors associated with abortion-seeking to which the study could not be sensitive. For example, the authors note that, ‘It is clear the decision to seek (or not seek) an abortion following pregnancy is likely to involve a complex process’, and consequently ‘it could be proposed that our results reflect the effects of unwanted pregnancy on mental health rather than the effects of abortion per se on mental health’.
This last point, about the effects of unwanted pregnancy, is especially important. Three groups of women were compared in this study: women who said they had an abortion, against women who had not experienced a pregnancy and women who had continued a pregnancy to term. It was against this background that an association was made between abortion and poorer mental health. Yet the study was conducted in a context where abortion is legal, and relatively freely available. So it must be taken into account that, among these three groups of women, it will likely have been those whose pregnancy was truly and consistently unwanted who went on to have an abortion.
In other words, it may be the fact that their pregnancy was unwanted and possibly seen as a burden, rather than the fact they had an abortion, which contributed to certain states of mind.
The most valid comparator group to women who have an abortion is not women who have not experienced pregnancy or women who have given birth because they want to, but rather women with unwanted pregnancies who are denied abortion and who then give birth. When these two groups of women – those with unwanted pregnancies who opt for abortion and those with unwanted pregnancies who are denied abortion – are compared, we can at least be pretty certain that the context of pregnancy is similar for both, and that what is being compared is the effects of the resolution of the pregnancy (birth or abortion) on the women’s state of mind.
Yet this latest study did not include a group of women who were denied abortion, which is understandable, given the relatively free abortion laws in New Zealand. Other research has shown that lack of choice in continuing an unwanted pregnancy has a stronger association with poor mental health than abortion.
The authors of this latest study are right to be tentative in their conclusions. They are correct to conclude that ‘the issue of whether or not abortion has harmful effects on mental health remains to be fully resolved’, and to call for more research into the area.
In taking this approach they also reflect what seems to be a consensus in this area of abortion research. Academic research about the psychological effects of abortion is widely recognised as a complicated enterprise. As noted by American psychologist Henry David, a prolific writer on this subject, designing research that can make definitive statements about the psychological effects of abortion, and other reproductive events, is a complex task – far more complex than research on abortion and physical health, where it can be clearly stated that abortion is a relatively safe medical procedure.
For this reason, the British Royal College of Obstetricians and Gynaecologists (RCOG) wisely takes stock every now and then of the range of published studies on the issue, before drawing up its evidence-based guidelines for British abortion providers. In its leaflet for women considering abortion, the RCOG says: ‘How you react will depend on the circumstances of your abortion, the reasons for having it and on how comfortable you feel about your decision. You may feel relieved or sad, or a mixture of both.’ It also notes that: ‘Some studies suggest that women who have had an abortion may be more likely to have psychiatric illness or to self-harm than other women who give birth or are of a similar age. However, there is no evidence that these problems are actually caused by the abortion; they are often a continuation of problems a woman has experienced before.’
This reads as a balanced approach, taking careful account of the available evidence. It tells women and their loved ones about the general conclusions of published, peer-reviewed evidence. This is in stark contrast to the line taken by the letter-signers to The Times, who called for British medical authorities to change the way things are. On the basis of one study from New Zealand of women aged under 25, which actually makes only tentative claims and recommends further research, the signatories claim that ‘doctors [in Britain] have a duty to advise about the long-term psychological consequences of abortion’.
How did they come to this conclusion? The emphasis on the ‘risks of abortion’ and their alleged implications for abortion practice arises, not from any balanced consideration and debate about well-designed academic research, but from political attitudes to abortion.
Today, those who are hostile to abortion find it difficult to frame their arguments in moral terms. For a range of reasons, very few will agree these days that abortion is simply ‘wrong’, and so there is little support for attempts to moralise against abortion. At the same time, the language of risk increasingly provides a medicalised vocabulary in which anti-abortion arguments can be made. In effect, we have the ‘medicalisation’ of anti-abortion arguments through the use of the language of risk. Those of us who support a woman’s right to choose should challenge this new anti-abortion focus, and demand a higher standard in discussions of research and evidence.
Dr Ellie Lee is author of Abortion, Motherhood and Mental Health: Medicalising Reproduction in the US and Britain, published by AldineTransaction, and coordinator of the Pro-Choice Forum.
References:
‘Doctors’ letter sparks debate over abortion and mental health’, Abortion Review, 30 October 2006
‘The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7’, RCOG September 2004
‘Abortion in young women and subsequent mental health’. Fergusson DM, Horwood LJ, Ridder EM. Journal of Child Psychology and Psychiatry. 2006 Jan; 47(1): 16-24.
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