one abortion (wema study) - children by choice · kinda-it was stupid because i wasn’t on any...

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.

Women’s experiences of more than one abortion (WEMA study)

Dr Catriona Melville

Unplanned Pregnancy and Abortion in Australia Conference, Brisbane, 3-4 August 2017


Overview

• Scottish/UK context

• Findings from study of women’s abortion experiences in Scotland

• Discussion of implications & recommendations


Scotland

• Population ~5.4m

• Largest city - Glasgow ~500K

• Range of rural, remote and island communities

• Poor health record in comparison to other European countries

• Considerable inequalities between different social groups and regions

http://commons.wikimedia.org


Health in Scotland

Health care is devolved to the

Scottish Government

Abortion available via the

publicly-funded National Health

Service (14 regional NHS boards)

The 1967 Abortion Act

- Available to term to save the life of the pregnant woman, where her physical or mental health is in grave danger, or for severe fetal anomaly

- Also allows for abortion up to 24 weeks’ gestation for psycho-social indications: where two doctors agree that there is ‘greater risk than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman’ (Ground C)

http://commons.wikimedia.org


Abortion in Scotland

• Standards in place to ensure access

• Gestational limit 24 weeks (under Ground C)

• >70% under 9 weeks gestation and majority are medical

• Legally required to notify Chief Medical Officer in Scotland of all abortions

• Information Services Division (ISD) collects data derived from notifications


Abortion in Scotland (2016)

• 12,063 abortions (representing a rate of 11.6 per 1000 women aged 15-44 years)

• Abortion rate highest in 20-24 years age group (19.5 per 1000)

• In areas of high deprivation the rate is 15.9 per 1000, nearly double the rate of 7.8 per 1000 for the least deprived areas of Scotland

Information Services Division (ISD) NHS National Services Scotland. Abortion Statistics. Year

ending 31 December 2016. Edinburgh: NHS National Services Scotland, 2017


Why is ‘repeat’ abortion of interest?

• Commonly framed as a concern for abortion provision, policy & research in the UK and globally

• Expressed desire to reduce ‘repeat’ abortions, even in a context where abortion law is relatively liberal

• Concerns : unmet contraceptive needs; cost implications of abortion provision; short interpregnancy intervals; and drives towards patient-centred care

• Scholarship has problematised a focus on ‘repeat abortion’

• Potentially discriminatory and stigmatising assumptions which underpin it

• Even the language itself is inherently judgemental of the women involved


Framing of ‘Repeat’ abortion

• Distinction between ‘good’ and ‘bad’ reflected in policy discourses

• Reports on abortion statistics typically single out and highlight ‘repeat termination’ as a problem

ISD Scotland Termination of Pregnancy report 2015

• Existing research suggests:

• ‘repeat’ abortion viewed as indicator of service failure

• yet, ‘repeat’ incidences are experienced very differently by women


Previous research

• Associated factors wide ranging e.g. characteristics of the women, contraceptive (non)-use, broader contextual factors including deprivation and intimate partner violence (IPV)

• Limited UK research showed:

• 1/3 women who had undergone 2 abortions had the second within two years of the first

• 60% had their second within 5 years

Stone N, and Ingham, R. Who presents more than once? Repeat

abortion among women in Britain. Journal of Family Planning

and Reproductive Health Care. 2011;37(4):209-15.

• No Scottish specific research and no research with fixed time intervals


Previous abortions in Scotland: 2006-2016

ISD NHS National Services Scotland, 2017

2016 – 3,881 ‘repeat’ abortions, rate of 3.7 per 1,000 women aged 15-44

Crude rate of proportion of women who have had more than one abortion and the time lapse between abortions is not reported

(despite a commonly cited ‘concern’ that abortions are frequent and being used as contraception)


• Study commissioned & funded by the Scottish Government

Women’s Experiences of More than one Abortion


Women’s Experiences of More than one Abortion

Research questions

1. Characteristics of women seeking more than one abortion

2. Proportion of subsequent abortions occurring within 2 years

3. Reasons for seeking more than one abortion in 2 years

4. Experiences of undergoing more than one abortion in 2 years

5. Opportunities for intervention to reduce the incidence of ‘repeat’ abortion?

• Mixed methods study

• 6 NHS health board areas, 6 month recruitment period (2015)

• Questionnaire responses from 1662 women who sought abortion

• In-depth interviews with 23 women who had undergone more than one abortion within two years


Participating areas

Highland

GreaterGlasgow& Clyde

Ayrshire& Arran

Grampian

Lothian

Recruitment centres accounted for over 70% of the ‘repeat’ abortions recorded in Scotland , and served a mix of urban and rural populations

Tayside


Quantitative survey

• Anonymous self-completed questionnaire based on pre-validated questions

• Demographics, deprivation category, relationship status, smoking and alcohol, and IPV

• Gestation, previous abortion, contraceptive history

• 4415 women underwent abortion during the recruitment period, and 1662 complete questionnaires were collected (38%)


Research questions



Results: sample characteristics (all women)

• Mean age 26.1 years (range 16-47)

• 82.6% (n=1373) presented at ≤9 weeks of gestation

• 60.8% reported at least one previous pregnancy, and 47.2% had children

• 72.2% (n=1200) reported contraceptive use in the month prior to their most recent conception, although 31.5% (n=524) indicated inconsistent use.

• Most were in a relationship/married (73.8%, n=1227)

• 24.7% (n=410) reported experience of IPV (ever), with 27.8% (n=114) of that group reporting IPV experienced in the preceding 12 months.


Research questions




Results: previous abortions

• Of the total questionnaire sample, 34.4% (n=571) reported a previous abortion, 14.6 % (n=242) within the preceding two years


Comparing characteristics

• More commonalities than differences between women who had undergone more than one, and any women seeking, abortion

• Only a few differences relating to age, relationship status, and experience of domestic abuse

• Woman who had undergone a previous abortion were :

• more likely to report intimate partner violence (IPV) than those who had never had an abortion

• more likely to ‘always use contraception’ than those who had never had an abortion


Research questions





Reasons for more than one unintended conception

• Majority of participants reported contraceptive use in the month prior to conception, which suggests that abortion itself was not being used as contraception

• Most reported uptake of methods known to be less reliable

• Reasons for unintended conceptions in qualitative sample

• Contraceptive method failure (n=14)

• Contraceptive non-use(n=9)


Contraceptive use

• Women described difficulties with multiple methods of contraception, primarily relating to unwanted side-effects

• This highlights the difficulties faced by women as they try to effectively contracept

• Non-use of contraceptives related to partner refusal/reluctance to use condoms (issue of control exercised by male partners over which they had little influence)


Reasons for more than one unintended conception

• Commonly described in highly negative terms, or defending against negative assumptions

• Absence of contraception was explained in highly self-critical terms

• Feelings compounded by negative attitudes of health professionals

“It was twelve weeks after I had [son], I fell pregnant again, but that was- it was kinda- it was stupid because I wasn’t on

any contraception at that time. So, I kinda fell pregnant fast and I felt that it

was too soon” (Nicola, 24, 3rd abortion)

“I do beat myself up about it, y’know, the fact that it’s happened three times. But then I think to myself, it wasn’t

through pure stupidity, it wasn’t that I was going out and having a one night stand and then it was just happening […] We were using protection– we were using condoms, I was on the pill”

(Rachael, 29, 3rd abortion)


Main reason for seeking abortion at current and previous abortion within two years (n=242)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Did not want achild/ any more

children

Work or livingcircumstances

Partner/ familyissues

Felt too young/ tooold to have a child

Health & wellbeing(of

woman/children)

Not ready for thisparticularpregnancy

Other/multiplereasons

Most recent TOP

Previous TOP <2years


Main reason for seeking abortion

• The main reason cited by the majority of the quantitative sample for seeking each abortion within two years was that they ‘did not want a child/ any more children’

• Qualitative data suggested that reasons were complex and overlapping and demonstrate a range of potential vulnerabilities among women seeking more than one abortion


Women’s reasons for more than one abortion

• Reasons included:

• not feeling ready for a child; not wanting children at all

• not wanting a(nother) child at that time

• not being in relationship with the man with whom they had conceived

• not feeling financially stable enough to continue the pregnancy

• being in full-time education / not in an established career

• concerns regarding the impact of the pregnancy on existing children

• Some reported similar reasons/circumstances at each abortion

• While reasons may have remained constant, many experiences still tended to differ, meaning instances remained distinct and relatively unique


Potential vulnerabilities of women seeking more than one abortion

Relating to:

• the presence and availability of support from male partners

o in armed forces; working away/offshore; in prison

• woman’s own physical and mental health

• their life opportunities

• domestic violence / abuse - reported by 8 of 23 interviewees

• Important to reflect that women seeking more than one abortion could be a particularly vulnerable group

“…we were officially together a week, I ended up falling pregnant. So I was like: ‘well, we don't know each other yet’ […] So that's when I had my first termination. An' then six months down the line […] I fell pregnant again. But by that time he started getting… really controlling and quite violent. So I was like: 'I cannae

do this‘. So I thought I kinda- to try an' get him out my life, I couldnae continue the pregnancy. So I had my second termination. […] They [her children] only seen him push me to the ground, but that's mair [more] than I want them to

see.” (Frances, 25, 3rd abortion)


Intimate partner violence

“We had been together for about a year, we had our own place, we were at university. [We were] planning to get married […] But then our relationship started taking a strange turn. He was diagnosed with depression before I met him, so I knew about that. But there was this compulsive lying going on, there was strange things happening.[…] There was a couple of times that got physically violent. […] It ended up in a really bad argument, [a] fight which ended up with me having my knee slit open with a knife [and] a door smacked in my face, which chipped my teeth.” (Anna, 23, 2nd abortion)

• Anna went on to explain that she would feel “too guilty” if she brought a child into this environment


Research questions




4. Experiences of undergoing more than one abortion in 2 years


Experiences of more than one abortion

• Complex, varied and distinct on each instance (for most women)

• Women’s reflections related to:

o experiences and expectations of health professionals

o comparisons between episodes of care (‘going back’)

o knowing what to expect

o awareness of the availability of subsequent abortion

o feelings about having undergone more than one abortion

“It’s crazy to think how different they were actually. […] I can’t really think about anything that was similar to be honest. They just seem totally from, y’know, how I felt about it to, like, the route to, like, trying to get it done, to the actual procedure

itself, felt totally different.” (Anna, 23, 2nd abortion)


Experiences and expectations of health professionals

• Avoiding GPs (general practitioners) for fear of judgement

• Some health professionals found to be empathetic and non-judgemental

• Others found to have negative attitudes – implicit and explicitly

“the second time I was kinda scared to

go to my GP so I went to the [SRH]

clinic. And the woman was really, really

cheeky. I mean she was nasty, she

made me feel terrible. [CP: So, like,

what happened?] I said I had had a

termination before, I’d been on the pill,

and I took the morning after pill, and

obviously I’d fell pregnant again. And

she was really cheeky, like: ‘Do you

not think you could have been

safer? This is not that long ago that

you had a termination. I think you

need to start using your head.’

(Nicola, 24, 3rd abortion)


‘Going back’

• Acute feelings of shame, guilt, self-consciousness

• Medical gatekeeping as a barrier to subsequent abortion

• Attempts at self-abortion, alternative routes

“It was the whole having to actually… y’know, speak to people and have to tell them why I’m here again, y’know? […] The last thing I wanted to do

was have to go back up to the hospital and go through… and say: “Oh, well, I’m back again” […] So I looked to see if there was anything I

could do myself about– [because] at the end of the day, it was just a tablet they pretty much give to you - whether I could’ve bought that myself online, or is there something I could do naturally, myself, to get rid of the pregnancy.

So that’s what I did. I tried to do anything not to have to go back.’ (Becca, 37, 2nd abortion)


‘Knowing what to expect’

• Prior to approaching services and/or regarding the procedure

significantly reduced anxiety in anticipation of a subsequent abortion

• Suggests women can cope with the procedure

• BUT not knowing what to expect of health professionals / expecting the same negative attitudes as previously experienced

suggests this may constitute significant barrier to access

“…the first time I was a lot more nervous, ‘cause obviously it was the first time I’d went

through that. But the second time, […] knowing what I was going to go through. It was definitely

a lot easier the second time round. Just because of that previous experience.”

(Chloe, 20, 2nd abortion)


Availability of subsequent abortion

Participant had concerns re:

• Whether they were entitled to more than one (on NHS or at all)

• Whether it was medically advisable

• Harm to their mental health

• Harm to future fertility

“I'd actually heard that you couldn't have more than two

abortions. […] So that was quite a big stress for me when I went in the second time. And the doctor was just like: ‘No. That's not

true at all’. (Emily, 19, 2nd abortion)

“I don’t see it as: ‘I’ve had one, I’ve had two, I’ve had three’. I see it as: ‘Shit, now I’m gonna have less change of falling pregnant when I actually do want to’

[…] With my second pregnancy it was like: ‘Oh your % of falling pregnant comes down each time an’ goes from like 100% to like 70%’ […] That was from the [hospital].

(Olivia, 21, 4th abortion)


Feelings about having undergone more than one abortion

• Tendency toward non-disclosure of subsequent abortions

• For some this related to increased feelings of control/agency

• Also reflected concerns about being judged

“…it wasn’t that we were ashamed of it. I just didn’t really want to tell everybody I was going through a second one, like, four months, five months later. […] I feel that people maybe would judge me a little bit more. Whereas all my

friends were so supportive the first time, I don’t know whether they’d be as supportive the second. […] I feel like there is a stigma around it and it’s annoying

that there’s a stigma.” (Isla, 22, 2nd abortion)

“… the first time […] taking my mum and, like, having my boyfriend at the time very involved in it made it a lot more… I would say it made it harder for me if I was

honest, 'cause I felt like it made it into kind of a bigger deal […] than I would have preferred. So this time it was a lot

more calm” (Emily, 19, 2nd abortion)


Conclusions

• Women’s circumstances and reasons for seeking more than one abortion are not dissimilar to those of any women seeking abortion

• Women undergoing abortion more than once in 2 years are not treating abortion ‘like contraception’

• Contraception was an issue, but by no means the only one

• For all women, there was consideration of whether they could cope with a pregnancy and having a child: financially, practically, and emotionally

• Complex and overlapping issues demonstrate a range of potential vulnerabilities (including IPV) among women seeking more than one abortion


Conclusions

• The consequences of abortion stigma for women having more than one abortion were clearly evident

• A disproportionate focus on ‘repeat’ abortion exacerbates stigmatisation

• It distracts from a more productive focus on improving abortion provision

• Current framings of ‘repeat’ abortion may contribute to constraining women’s reproductive decision-making


Recommendations: interventions?

• Rather than a policy focus on trying to reduce ‘repeat’ abortions, we should shift the focus to preventing unintended conceptions and supporting those who need subsequent abortions

• Encourage use of the most effective contraceptives methods, and greater provision for women who present for abortion

• This should go hand in hand with attempts to challenge the prevailing negative social attitudes to abortion that currently exist (including health professionals)


Recommendations

• Abortion provision should be considered as essential in enabling women to have the kinds of families and life outcomes that they want

• Encouraging and promoting a more positive view of women accessing abortion more than once to situate it as essential healthcare provision, rather than something exceptional and stigmatising

• This will represent a step toward situating abortion more clearly as an issue of

o gender equality

o social justice


Acknowledgements

• All of the women who took part in the WEMA studies

• The research team

• Carrie Purcell – MRC/CSO SPHSU

• Julie Riddell – MRC/CSO SPHSU

• Sharon Cameron – NHS Lothian

• Audrey Brown – NHS Greater Glasgow & Clyde

• Catriona Melville – NHS Ayrshire & Arran

• Gillian Flett – NHS Grampian

• George Laird – NHS West of Scotland Sexual Health Managed Clinical Network

• Lucy Caird – NHS Highland

• Yeshi Bushan – NHS Tayside

• Our funders: The Scottish Government


Email: [email protected]

Thank you

one abortion (wema study) - children by choice · kinda-it was stupid because i wasn’t on any...

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