Ann Furedi, Chief Executive of British Pregnancy Advisory Service, gave the following speech to Medical Students for Choice in the US on 17th October 2015.
There are many debates about the language that is used in reproductive healthcare. But most of them don’t matter very much. Should we talk about ‘termination of pregnancy’ or abortion? About a fetus or a baby? Most of the time we are led by the language used by our patients. We adapt to how they view their procedures.
When it comes to advocacy, however, language does matter. Because when we change our language, we are changing our ideas, we are changing what we say. Today, some of our sisters are arguing that we should drop the term ‘reproductive choice’ and replace it with reproductive health or justice. And I want to give a personal account of why I don’t agree, and why I am delighted that you, the Medical Students for Choice, have asked me to talk on ‘Why the Fight for Reproductive Choice Matters’.
For me, there is a difference between supporting women’s choice and supporting their reproductive health. It can be the same sometimes, yes; but it can also be very different. I witnessed this for the first time when I was living in East London about 30 years ago, in an area known as Tower Hamlets, which had a large Bangladeshi population. This was a time when there was a significant level of racist attacks, and I was one of the organisers of a group called East London Workers Against Racism. We helped to organise community defence against physical attacks by activists from the far-right National Front.
As it turned out, while we were focused on this explicit racism, the women of the community were being subjected to a more insidious form of racism. It was being perpetrated, not by skinheads with knives and bottles, but by liberal doctors, very like ourselves, motivated by (probably genuine) concern for the health and wellbeing of the community.
They held the view that women must be feeling exhausted by their large families, that children suffered from overcrowding in small flats, and that women would therefore benefit from better contraception. Depo Provera injections seemed a good solution. There were no complicated instructions to confuse women who had low literacy skills, and controlling husbands didn’t need to know about it. The main problem was that in the desire to get women to do what the reproductive-health doctors thought best for them, little attention was paid to making sure the women knew exactly what the injections were for. And it gradually emerged that many of these women, given long-acting injectable contraception, thought that they were receiving vitamins or being immunised against disease. No one had asked them about their preference. Their decision their choice about childbearing had been taken out of their hands, in the interests of public health and a doctor’s opinion about what was most beneficial for the community.
The treatment may have been well intentioned. Some of the doctors involved may have thought they were helping women who were powerless and uneducated and unable to take control of their lives. But in truth, they were taking control away from the women. They treated these women like children, incapable of making choices for themselves. Actually, they treated them like animals, as less than human.
To stay with reproductive health in the UK: compared to the US, much of what we have in Britain is good. We benefit from a National Health Service that pays for abortion for almost all British residents. And those abortion services are safe and regulated. But, here’s the rub: no woman can freely decide of her own volition to end her pregnancy. Two doctors must certify that she meets the legal grounds for abortion, which are that the abortion will be better for her health than having a child would be, or that there is a substantial risk of serious birth defects. The law is interpreted liberally, but still, granting an abortion is in the doctor’s gift. In effect, women can only obtain an abortion by claiming that they can’t cope with a child. It’s degrading and demeaning, and it denies the woman control over her body.
There is no recognition in the law that women are competent to decide by themselves if they wish to be pregnant. There is no respect for a woman’s autonomy, or for her moral determination about what is right or wrong for her or her family. The most personal, intimate decision — whether or not to have a child — is taken out of her hands. The law works to protect reproductive health, but it denies women the ability to make their own choices. It has no respect for women’s dignity.
We need to think carefully about what we advocate for. What kind of laws do women want and need? This question is posed starkly in the Republic of Ireland, where there will soon be a referendum that is likely to remove the constitutional ban on abortion. But what should it be replaced by? Unless we start to build a case that women can be trusted, and that abortion can and should be left out of criminal statutes and treated as a private decision, as a matter of ‘choice’, then it is likely that the British ‘health’ model will be adopted in Ireland, with all of its flaws but maybe not the will to work around them.
So why is it so difficult to accept that the idea of choice should be defended? Why the rush among even those who support the provision of abortion services to replace ‘choice’ with the rallying cries of ‘justice’ or ‘health’? Does choice seem too whimsical? Are we afraid that, left to themselves, women will make a ‘wrong decision’? But who can make a better decision than the woman herself about her own circumstances? And, crucially, if she doesn’t make the decision, how can she take responsibility for it?
I’ve been told that women cannot make choices freely; that women do not choose abortion, but are driven to it; that women say they have ‘no option’. But this doesn’t really make sense, in anything other than a rhetorical fashion anyway. Because different women make different decisions, even when they are in the same circumstances. Not every woman with a fetal diagnosis of Down’s syndrome chooses abortion. Some will see it as an opportunity to bring a different kind of person into their family. Some women deserted by their partners may hate the idea of their baby; others will see the baby as a legacy of the love two people once shared. We are not determined by our circumstances. Our social circumstances shape us, for sure, but they don’t determine what we do. We choose differently.
I’ve been told that choice is a too consumerist phrase, that it’s an economic term. Who made this up? Look up choice in Webster’s Dictionary, and you will see it defined as a ‘preferential determinant between things proposed’. The Oxford English Dictionary puts it even more simply: choice is ‘a decision between two or more things’. There is nothing consumerist about the word choice. If people believe this word is trivialising, what they’re really saying is that there is no value in decision-making — and we need to put them right on that.
Of course, the choice between having a child and having an abortion is not the same as a choice between two pairs of shoes, or between a latte and an espresso. But surely we believe that it’s not beyond understanding that all sorts of choices in life are different, and that some are more serious than others — and indeed that some are brutally difficult, with neither option being what you want. Women know this, and they cope with it because this is the context of many decisions in life.
I’ve also been told that choice is ‘privileged’. That only privileged women are concerned with choice, and only privileged women can exercise choice. Well, tell that to the Bangladeshi women in east London who were presumably seen as too underprivileged to appreciate the choice not to accept Depo Provera. Tell that to the abused woman who has chosen to leave her husband, or indeed the one who chooses to stay for the sake of her children. Because sometimes, knowing that you personally have made a decision is what gives you the courage to follow it through.
I cannot think of a more patronising, degrading way to talk about oppressed and marginalised people than to say that they have no choice about their pregnancy. What choice will we next decide they ‘can’t exercise’?
We need to make a stand for choice, for our ability to state a preference. Making choices, and trying to make our choice a reality, is one thing that, as individuals, we all share. When we acknowledge the importance of choice, it shows that we respect people for the individual, rational and reasonable creatures they are. It shows that we ‘trust women’, as the great Dr George Tiller advised us to. And that we trust them, not in an empty, rhetorical way, but because we see them as individuals who can make decisions, take responsibility, and determine their destinies.
Abortion – the law is failing women
In a week where women’s rights occupied a significant number of column inches with the release of the film Suffragette, Professor Sally Sheldon turned the spotlight on a legal relic still controlling women’s bodies in 2015: our abortion law. It may come as a surprise to many to hear that abortion without the permission of 2 doctors is a criminal offence, carrying a penalty of life imprisonment, under a Victorian Law – still on our statutes – passed before women even had the right to vote. As Sheldon argues, it is absurd that in 2015 women do not have full bodily autonomy and the right to make fundamental decisions about their own fertility. Aside from our abortion law, we are witnessing the failure of other legislation to support women seeking abortion care as they continue to be routinely harassed on their way to clinics, reported by Buzzfeed. However, overseas in Australia, change is underway. The state of Victoria, Australia, is set to establish 150 meter protest exclusion zones outside clinics free from harassment and intimidation by anti-abortion campaigners. We hope Theresa May is taking note….
More contraceptive control for women
Contraceptive innovation is all too rare so we were very pleased to hear that women who opt for the contraceptive injection will now be able to self-administer at home. Previously, women would have to go to their GPs or sexual health clinic once every 3 months for the injection, but now women will be able to skip these more time-consuming regular visits in place of an annual check up. The need for fewer appointments aside, developments that put control over contraception and fertility directly in to women’s hands is a good thing. As our very own Champion of Choice Dr Christian Jessen argued in the Metro, the “more choice and the more power” women are given over their own bodies, the better their health outcomes will be. We couldn’t have said it better ourselves Dr Christian!
Alcohol, pregnancy, and respecting women’s autonomy
A British Medical Journal “head-to-head” debate lead to some rather confusing coverage about the impact of drinking during pregnancy. It was an interesting piece in the BMJ, exploring not only the evidence base for guidance but also the relationship between clinicians and patients and how we articulate complex information around risk. Sadly, the nuances were missed, and the coverage presented the article as “doctors advising women to abstain”, largely ignoring the solid rebuttal by Dr Patrick O’Brien from the Royal College of Obstetricians and Gynaecologists. We couldn’t help but cheer Dr O’Brien for advocating for respect for pregnant women’s autonomy and capacity to understand information and make their own decisions. Indeed, a recent study on the prevalence of drinking during pregnancy demonstrated that the vast majority of women drink within current Nice guidelines after finding out they are pregnant – more evidence that scaremongering is simply unnecessary.
The rise and rise of older motherhood
New statistics have been released showing there are more women over the age of 35 giving birth than under the age of 25. There are a whole host of reasons as to why women delay motherhood such as career development, the ever-increasing cost of raising a child or simply that women want to wait until they “settled in other areas of their lives” as Harriet Hall states in Stylist. Radhika Sanghani brilliantly argues that the reality is there is no right age for women to choose to have children. So, rather than pushing women into having children when they’re not ready or stigmatising them for having them too early (another case of women can’t win) wouldn’t it be better if the focus was placed on supporting women to have children at a time that is right for them?
Fighting abortion stigma
The internet was taken by storm this month with thousands of tweets and stories written by brave women sharing their abortion story, or supporting others that have done, as part of the #ShoutYourAbortion trend. The campaign may have begun in America, but as Milli Hill points out, it became a global phenomenon because pro-choice advocates around the world are facing the same constant attacks on abortion provision and the “othering” of women who need abortion care. Campaigners in Ireland also spoke out last month to challenge abortion stigma in their home country, with a number of celebrities and activists “outing themselves” as having had an abortion. This trigged a flurry of Irish women writing about their abortions, ahead of the 4th Annual March for Choice which saw thousands take to the streets in Dublin. We really recommend this video of one of our Champions of Choice Mara Clarke of the Abortion Support Network speaking passionately about the experiences of women forced to travel for abortion care.
Champions of Choice in the News
In excellent news our Champion of Choice the wonderful Caitlin Dean, Nurse and Chair of Pregnancy Sickness Support, has won a Third Sector Award for Charity Chair Person of the Year. Caitlin works tirelessly to support women suffering from hyperemesis and improve the services that are available to them whilst also campaigning to raise public awareness of the condition in a public. A huge congratulations to Caitlin and a well deserved win!
We would also like to take this time to nominate Clare Daly TD as a Champion of Choice for her brave and important campaign to bring abortion rights on to the political agenda in Ireland. She has spoken out at the Coalition to Repeal the 8th Amendment this month urging everyone to contact their TDs as well at the March for Choice. In a country where politicians fighting for women’s reproductive rights are a rarity, Clare’s commitment and passion in the battle for reproductive choice make her an invaluable Champion of Choice.
We were extremely pleased to see calls from Labour leadership candidate Yvette Cooper MP for the introduction of abortion clinic buffer zones. Cooper, who requested the government launch a consultation on buffer zones last year, stated: “Women should never be intimidated or threatened on their way to a healthcare appointment or on their way to work. No matter how strongly protesters feel about abortion themselves, they don’t have the right to harass, intimidate or film women who need to make their own very personal decision with their doctors. Everyone has the right to access legal healthcare, medical advice and support and to have some privacy and space to do so – and that includes abortion services.” Jeremy Corbyn MP, frontrunner in the leadership race, has also co-signed a letter to Health Secretary Jeremy Hunt MP to call for action on protest activity – needless to say, no official government response as yet…. For more information about the campaign for abortion clinic buffer zones, vist back-off.org.
Laura Wade-Gery, head of multi-channel at M&S, announced she was having her first child and given her age – 50 – the news was greeted with more finger wagging than mail order flowers. The “seasoned watchers of successful women” came out in force to judge every aspect of Wade-Grey’s pregnancy, from childcare arrangements after the baby arrives and whether or not she will have a c-section i.e. a range of personal decisions that are no-one else’s business. The ensuing debate only serves to highlight the absurdity of the notion of a universal “right” time to have a baby. Women are blamed, as Bidisha brilliantly argued in her Comment is Free piece, for being “feckless bimbos” if they have them in their early teens or “careerist monsters” if they have them in our 40’s. However this is a vilification reserved just for women – as Dawn Foster points out, any time is the right time to have a baby if you’re a man.
One in four pregnancies will end in miscarriage, yet it remains a highly taboo topic. Mark Zuckerberg’s challenged the silence and stigma by posting on Facebook that he and his wife had experienced a series of miscarriages. This in turn lead to a number of men and women making the brave decision to speak openly about their personal experiences. Zoe Williams piece exploring the impact of public health messaging on contribute to the sense of shame and guilt associated with miscarriage was extremely welcome. Even when well-intentioned, papers and headlines about the “potential, but unproven, risks” to a babies health from using new frying pans or having a glass of wine during pregnancy leave many women blaming themselves after a miscarriage. If we are encouraging people to speak openly about their miscarriage, then that honesty must be met with kindness – not blame.