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The battle for women's bodies

Seeta Bhardwa discusses the resurgent issues around abortion and the role of nurses and midwives

The recent prosecution of a young woman in Northern Ireland who purchased abortion pills from the internet has once again revived the debate around abortion. Just last week pro-choice campaigners across the border in Ireland expressed fears that political parties will rule out a referendum on abortion laws in order to shore up their Catholic vote, after an inconclusive election in February.

Abortion has always and will always be seen from a number of different viewpoints: medical, ethical, moral or religious.

However, many medical professionals do not believe that this should be the case.

Breedagh Hughes, the director for Northern Ireland at the Royal College of Midwives (RCM) says that the organisation has ‘quite clear views that abortion globally should be decriminalised and that there is nothing to be gained by putting a woman in prison when she has an obvious healthcare need’. Ms Hughes believes that viewing abortion as a criminal, moral, or socio-economic issue is missing the point. ‘I think abortion needs to be seen as a medical issue and an education issue as well.’

The 1967 Abortion Act in England, Wales and Scotland means that women are able to undergo abortions following assessment and the signatures of two doctors. Women in Northern Ireland however, are still forbidden to procure an abortion unless under extreme circumstances. There were 16 lawful abortions in Northern Ireland last year in comparison with around 200,000 in England, Wales and Scotland.

Ms Hughes argues that criminalising abortion will just drive it further underground and result in more women undergoing risky procedures and taking unregulated pills. Many women will travel across to England or Europe (this is not illegal) to undergo an abortion but this is dependent on financial circumstances.

Ms Hughes says that the number of women who give Northern Irish addresses at clinics in England has gone down. ‘However, we do not think this is because less women are having abortions, it may be because the number of abortions carried out in homes has gone up,’ she says.

She says this is ‘worrying’ as women can never be sure of exactly what is in those pills. It’s a 21st century digital resolution to an old kitchen sink problem. Thanks to the internet any woman can become her own Vera Drake, with all the attendant dangers.

At the end of last year the High Court ruled that current abortion legislation in Northern Ireland breaches Article 8 of the European Convention on Human Rights1 by failing to provide an exception in cases of fatal foetal abnormality or rape.

The Northern Irish health minister has since published updated guidelines on abortion which still did not qualify fatal foetal abnormality as a reason for abortion in its own right. But significantly it recognises that abortion pills are in circulation in Northern Ireland and that staff are able to observe patient confidentiality.

For a midwife or nurse working in Northern Ireland they could also face the risk of imprisonment if they advise or help women towards having an abortion.

‘The law here says that you can give a woman information and that’s it. You can’t give her advice, you can’t direct her to anybody, you can’t make a phone call on her behalf, because that’s seen as assisting her to procure an abortion,’ says Ms Hughes.

‘All you can do is give her written information or tell her to look at a particular website and then she has to do it all by herself,’ adds Ms Hughes.

Even if a woman has taken an abortion pill and experiences harmful side-effects, if she admits that to
a nurse or midwife, they are legally obliged to report her to the police.

‘If there is a little bit of tissue left behind it could cause infection or haemorrhage and in those cases women must be seen by a healthcare professional. Unfortunately, we have to adopt the “don’t ask, don’t tell” approach. It’s not a situation that we are happy with, we think there should be total openness between a woman and her caregiver,’ says Ms Hughes.

There are options for women seeking alternatives to abortion such as pregnancy advice charity Life UK. Marion Woods, the public policy spokesperson for the Northern Ireland branch of Life UK, says they believe that life begins at conception. ‘The government in Northern Ireland has placed a very high value on the life of the unborn child.’

Ms Woods says that women should be provided with all the options in front of her and then she can make a decision that’s right for her. As Life UK is a non-religious pro-life organisation, the advisors will present a range of different options for the woman. ‘We will discuss counselling, adoption and fostering and can help the woman to access the appropriate services.’

The charity states that it is usually external factors such as health concerns of the woman and the child, financial difficulties or age that are concerning the woman, rather than the pregnancy itself. ‘In these cases we would call for perinatal hospice care to give the woman and her partner the space and time to understand the condition of the child and to prepare for the potential death of the child. Or we provide housing for women to stay in for up to two years, until they get back up on their feet.’

Ms Woods says that in cases where the woman is ill, it is down to the doctor to decide on the best route to take.

The role of the nurse

In the rest of the UK, nurses are instrumental in advising and referring women on to the correct services. Nurses working in NHS-contracted clinics such as through the British Pregnancy Advisory Service (BPAS) or Marie Stopes will usually be a woman’s first point of contact in the process.

Dr Tracey Masters, consultant in sexual and reproductive health at Homerton University Hospital NHS Foundation Trust and spokesperson for the British Society of Abortion Care Providers, says: ‘I strongly emphasise that primary care nurses and midwives have an important role to play. They need to be aware of the referral pathway for a woman as abortion is a very common procedure. I think a lot of people don’t realise that at least one in three women have had an abortion.’

However, further along the pathway nurses are still locked out of the decision making process. They don’t have the power to sign off an abortion and are unable to carry out the procedures such as the manual vacuum aspiration or to prescribe the pills for a medical procedure.

Julia Bradley, the lead nurse at the South Buckinghamshire Cluster of BPAS, says that her role in the clinic is very varied, from providing women with contraceptive advice, advising on the medical procedure and carrying out assessments and scans to determine gestation length. She says there are currently discussions around allowing nurses to carry out the manual vacuum aspiration as it is similar to other gynaecological procedures.

‘As an STI nurse, I’ve put speculums in and swabs so it’s more of an extension of that. Within the medical profession there’s an understanding that it is a fairly straightforward procedure that a nurse is more than qualified to carry out. But I think that is still being discussed,’ says Ms Bradley.

Ms Hughes says that it is not just nurses working in clinics or in sexual health that will have to deal with abortion regularly. ‘It could easily be a nurse in an emergency department or a school nurse seeing a teenager or a practice nurse or a family planning nurse,’ she says.

Sex education
Providing well-rounded sex education and contraceptive advice is obviously not a silver bullet in reducing abortion rates but could at least be one method. A study in the Netherlands2 found that sex education and greater availability of contraception led to a reduction of teenage pregnancies.

As many of the schools in Northern Ireland are still governed by religion, many of the pupils at those schools may not receive any advice on methods of contraception.

Ms Bradley however, says that it is not just young women, but older women who find that sometimes contraception advice isn’t always up to scratch. ‘I had a lady in her mid-40s come into the clinic after accidentally falling

pregnant. Because she had a family history of breast cancer, her GP advised her to come off her regular method of contraception and she was not given an alternative.’

Abortion is perhaps one of the few issues where such polarised views exist in society. It still seems strange and a little archaic that in the 21st Century a women’s body and the choices she makes regarding her family are still defined by law and not her own mind. As Ms Bradley puts it: ‘There is no other medical procedure were a person would be grilled and assessed in this way. If a woman cannot get those two signatures she can’t have an abortion’.

But then abortion is not just like having an appendix out. The ethical complexities of abortion will always be picked over, but allowing nurses to be at the centre of caring for the woman should never be controversial.

1. Alan Meban. High Court rules NI abortion legislation breaches Article 8 of European Convention on Human Rights.

2.Ketting E, Visser AP. 1994. Contraception in The Netherlands: the low abortion rate explained.