ALRANZ News

Don’t forget to check out the new shared website at Issues.co.nz where you can also add comments in a blog. The ALRANZ pages were opened on 20 April 2009 and the campaign title is KEEP ABORTION SAFE AND LEGAL. Go to www.issues.co.nz/abortion 

Anti-abortionists have been active in the last few months attacking the Family Planning initiative at Hamilton. Watch the newspapers and internet blog sites and contribute to the debate when you can. It is important to correct the misinformation propagated by opponents. Since the last newsletter ALRANZ has sent out two national media releases on this topic and another directed at local Waikato media outlets. If you need information on medical abortion go to the homepage of www.alranz.org where you will find a pamphlet on medical abortion.

The NZ Parliamentarians’ Group on Population and Development chaired by Dr Jackie Blue held an Open Hearing at Parliament on 21 September 2009 on Maternal Health in the Pacific but did not discuss the topic of abortion rights for Pacific women even though this is fundamental to improving maternal health. ALRANZ made a written submission but was not invited to make an oral presentation.

Obituary

Sir Jack Harris (23 July 1906 – 26 August 2009) reached his 103rd birthday. At the age of 100 years he published his biography Memoirs of a Century. Sir Jack was born in London, educated at Cambridge and came to New Zealand during the depression to save the family importing business. On board ship, on his way to New Zealand, he met Patricia and they later married and raised three children. He inherited his father’s baronetcy in 1952. Lady Patricia became patron on the Abortion Law Reform Association from 1975 until her death in 2003. Sir Jack was always supportive of his wife’s involvement in ALRANZ.

Abortion Supervisory Committee (ASC) Report

On Friday 16 October at the Mifepristone in Australasia Conference, held in Wellington, Dr Alison Knowles, leader of the committee which developed the standards, launched the report Standards of Care for Women Requesting Induced Abortion in New Zealand. The document is primarily intended for those involved in abortion care and its aim is to ensure women have access to a service of uniformly high quality throughout NZ. The standards (82 of them) are intended to be mandatory and are designed to permit audit. Where outcomes are less certain practitioners have been given more flexibility and a number of recommendations have been made based on the best available evidence. The document will be revised as required by future changes in practice.

ALRANZ made a submission on the draft document and notes that many but not all of the recommendations were adopted. One of some concern is Standard 11 “Women must not wait longer than two weeks from time of referral to time of procedure. However some women may choose to have more time for decision making.”  Because there may also be delays seeing a doctor in the first instance the total waiting time may well be in excess of two weeks which is unacceptable when optimum care means carrying out an abortion as early as possible. Another recommendation not adopted was the need to provide better protection for patients and staff from anti-abortion protesters outside clinics.

Predictably Right to Life New Zealand (RTL) has criticised the document raising objections about the lack of emphasis on the psychological harm to women and the need for doctors to refer. To support his arguments Ken Orr quotes the Declaration of Geneva. [More on this later.] At the present time the Medical Council is working on a statement for doctors on Beliefs and Medical Practice which includes among other things, the referral by doctors with a conscientious objection to abortion.

Conference Report

180 delegates from Australia and NZ attended the Mifepristone in Australasia conference held in Wellington on 16-17 October 2009. Australians provided an update on their laws and regulations which vary from state to state (or territory). It was at this conference that the ASC’s Standards of Care document was launched. It was also an opportunity to launch another product for equipment to perform early medical abortions. This is a low tech, low cost, hand held vacuum syringe and the procedure is known as MVA (Manual Vacuum Aspiration). Experienced practitioners find it a gentle source of suction and much quieter than operating theatre equipment. While there is no need for this in a well equipped surgical theatre it is very useful in other clinic type situations. The equipment (syringe and catheters) can be used for other gynaecological procedures, diagnostic or treatment, such as performing an evacuation after an incomplete natural miscarriage. Istar Ltd the not-for-profit company which imports Mifegyne (mifepristone) into NZ is importing the MVA equipment.

Four international speakers provided an update from their various fields of expertise. Dr Christian Fiala  provides a private first trimester abortion service in Vienna, Austria. He studied medical abortion for his PhD at the Karolinksa University Hospital in Sweden and spoke on the pros and cons of different regimens that are used for early medical abortion. This can be quite confusing with different recommendations for the dosage of the mifepristone (the abortion pill) and the misoprostol (the prostaglandin given some time after the mifepristone), the timing between doses and the delivery of the misoprostol whether given vaginally or orally, either buccally (in the cheek) or sublingually (under the tongue). The aim is to provide the most effective regimen with the least side effects. Research continues.

Dr Helena von Hertzen has spent much of her professional life with the World Health Organisation based in Geneva and has been responsible for multinational research on emergency contraception and medical abortion. She recently left WHO to take up a position with Concept Foundation, a Bangkok based not-for-profit organisation promoting affordable healthcare in developing countries. Concept Foundation obtains supplies of mifepristone from an Indian manufacturer Sun Pharmaceuticals and distributes the product as Medabon, a low cost combination pack of oral mifepristone (one tablet) and misoprostol (four tablets) taken either vaginally or sublingually. The first countries to approve this product are Nepal and Cambodia.

Dr von Hertzen spoke on the problem of fatal infections affecting pregnant women in North America and whether or not these fatalities were related to the vaginal mode of administration of the misoprostol. It appears that the main problem is a particular type of organism Clostridium sordellii which causes toxic shock syndrome. It has not been a problem in Europe, Scandinavia or Australasia.

Ms Kate Paterson is an experienced clinician from London, a consultant gynaecologist at St Mary’s Hospital and a trustee of BPAS (British Pregnancy Advisory Service). She provided practical guidelines for doctors working in both first and second trimester abortion services and spoke on the recognition and management of complications in the hospital setting. In her experience mifepristone was a useful alternative in preparing the cervix for a late surgical abortion.

Joanne Fletcher is a consultant nurse from Sheffield Teaching Hospitals. She has postgraduate qualifications in genito-urinary medicine, counselling, leadership and management and a certificate in medical ultrasound – in other words an extremely well qualified nurse. Joanne was the first nurse in the UK to lead an NHS abortion service and spoke on the role of nurses in abortion care. Contraception and pain management received special attention. One of the most highly rated sessions was a presentation by nurses and counsellors of the support for women (and their partners) undergoing late termination.

One of the themes of the conference was how NZ laws are a barrier to providing an optimum medical abortion service. The following points were raised:

(1) The requirement that all abortions must be performed by a registered medical practitioner means that we are not utilising the skills of qualified nurses.

(2) The requirement that all medications must be given on premises licensed by the ASC means that home self-medication with the prostaglandin is not possible, whereas this is the preferred mode of delivery in other countries such as the USA.

(3) Dr Fiala informed us that in Sweden the taking of the prostaglandin at home is allowed because it was argued on medical and physiological grounds that it is the mifepristone which is the prime abortion agent and the taking of this marks the point of no return. With this precedent Mr Justice Durie’s decision could be challenged.

(4) Any procedural delays within the system mean that abortions are done at a later gestation. It was emphasised that the earlier an abortion is carried out the safer it is. NZ is not doing well in this regard although there has been an improvement in the last few years. In the Netherlands over 70% are carried out at less than 8 weeks.

Abortion Supervisory Committee court case

This case which has been winding its way through various court hearings since March 2005 continues. Following the hearing in the High Court in Wellington on 20 July Justice Forrest Miller released his judgment on 3 August. As predicted neither side, the ASC or RTL is satisfied with the outcome. No declarations were made and the ASC have lodged an appeal in the Appeal Court. RTL has counter-appealed. The case will most likely be heard early next year. More delays, more costs, no progress.

Medical ethics

Statements on professional ethics are living documents. While respecting the wisdom of the past they are also influenced by medical advances and societal changes.

The Hippocratic Oath (Hippocrates circa 460-370 BC)

Translations of this document from 4th Century BC vary but a commonly held version includes the statement: “I will not give a woman a pessary to cause an abortion.” In the past the Hippocratic Oath was often used at medical graduation ceremonies as the basis for a solemn pledge to uphold the ideals of the medical profession but it is no longer used in modern medical faculties.

The Declaration of Geneva

This modern version of the Hippocratic Oath was adopted by the World Medical Association (WMA) at its meeting in Geneva in 1948. The relevant section stated “I will maintain the utmost respect for human life, from the time of conception.” The Declaration was amended in 1968, 1984, 1994, 2005, and 2006 and now reads “I will maintain the utmost respect for human life.” There is no reference to conception.

The Declaration of Oslo

This directly addressed the question of abortion. The Declaration on Therapeutic Abortion was adopted by the 24th WMA in Oslo, Norway, August 1970 and amended by the 35th WMA Venice, Italy, October 1983 and the WMA General Assembly, Pilanesberg, South Africa, October 2006. The updated version now reads:

1. The WMA requires the physician to maintain respect for human life.

2. Circumstances bringing the interests of a mother into conflict with the interests of her unborn child create a dilemma and raise the question as to whether or not the pregnancy should be deliberately terminated.

3. Diversity of responses to such situations is due in part to the diversity of attitudes towards the life of the unborn child. This is a matter of individual conviction and conscience that must be respected.

4. It is not the role of the medical profession to determine the attitudes and rules of any particular state or community in this matter, but it is our duty to attempt both to ensure the protection of our patients and to safeguard the rights of the physician within society.

5. Therefore, where the law allows therapeutic abortion to be performed, the procedure should be performed by a physician competent to do so in premises approved by the appropriate authority.

6. If the physician’s convictions do not allow him or her to advise or perform an abortion, he or she may withdraw while ensuring the continuity of medical care by a qualified colleague.

The Tokyo Declaration

Within our geographical region The Asia and Oceania Federation of Obstetrics & Gynaecology (AOFOG) adopted The Tokyo Declaration at the XXth AOCOG meeting 21-25 September 2007, Tokyo, Japan. It is a position statement on preventing unsafe abortion.

The AOFOG recognises the magnitude of the problem of unsafe abortion and the need to address this issue. To this end the Obstetrics and Gynaecology Societies in the Asia Oceania region and their members will work proactively to accomplish a number of practical objectives which are listed.

The Code of Health and Disability Services Consumers’ Rights (1996)

In New Zealand a code for patient rights was established that has had a major impact on the doctor/patient relationship. The code addresses issues of safety, quality care, and privacy. It protects the right of women to be given accurate information to make an informed choice and give informed consent. The patient code of rights includes several which are applicable for abortion care but none more so than the one on decision making:

Right 7. It’s Your Decision You should receive a service only when you have made an informed choice and given your informed consent. You should be presumed to be competent to make choices and give consent unless there are reasonable grounds for a provider to conclude otherwise. If you have diminished competence (for example, a child) you should be allowed to make choices and give consent to the level of your ability. In circumstances where services have to be delivered without your consent, they should be in your best interests. Steps should be taken to discover whether services would be consistent with your wishes, including discussing the matter with available family and close friends. You may make a decision in advance, in accordance with common law. Your consent should be obtained in writing when you will be involved in research, an experimental procedure, a general anaesthetic or where there are possible significant adverse effects. You may refuse services and withdraw your consent. You may change to another procedure where it is practicable to do so. You may make decisions about body parts or bodily substances.

Abortion and mental health

Fergusson, Horwood & Boden have published another article in this month’s British Journal of Psychiatry entitled “Reactions to abortion and subsequent mental health”. This is the fourth article on the 1977 cohort of women from Christchurch. The first paper in 2006 was entitled “Abortion in young women and subsequent mental health” and was published in the Journal of Child Psychology and Psychiatry. It reported a possible harmful association between abortion and mental health but also said more research was needed.

The second paper in 2007 was entitled “Abortion among young women and subsequent life outcomes” and was published in the journal Perspectives on Sexual and Reproductive Health. Maybe because this reported some positive outcomes it received less publicity. Women having abortions had advantages in terms of educational and economic outcomes.  

In 2008 Fergusson wrote an editorial entitled “Abortion and mental health” published in the Psychiatric Bulletin calling for more and better research.

A third paper on the cohort in 2008 entitled “Abortion and mental health disorders: evidence from a 30-year longitudinal study” was published in the British Journal of Psychiatry. A finding was that abortion could account for only 1.5 to 5.5 per cent of the overall rate of mental disorders. In the latest article the time line is extended to include interviews at age 30 years. It concludes (not surprisingly) that abortion was associated with both positive and negative reactions. Importantly 90% were satisfied that they had made the right decision and only 2% regretted the decision. This refutes the claim of anti-abortionists that large numbers of women have regrets.

Decriminalisation in Europe

On 18 March 2008 the Parliamentary Assembly of the Council of Europe passed a resolution recommending the decriminalisation of abortion in all member states but opponents are fighting back. The Assembly was due to debate a pro-choice report Fifteen years since the International Conference on Population and Development Programme of Action authored by veteran British MP Christine McCafferty, but the vote has been delayed due to amendments tabled by an Italian parliamentarian, Mr Luca Volonte. The report will now be considered by the Assembly’s Social, Health and Family Affairs Committee which is chaired by Mrs McCafferty at a meeting in Paris on 13 November. Mrs McCafferty is also proposing a second report Women’s access to lawful medical care: the problem of unregulated use of conscientious objection which has the support of the Center for Reproductive Rights.

Overseas News

Ireland

Abortion is illegal in the Republic of Ireland (more precisely, it is illegal except where there is a real and substantial risk to the life, as distinct from the health, of the mother), as well as in Northern Ireland, and little progress toward choice has been made in recent years. An estimated 6,000 women travel from Ireland to the UK for abortions each year, though the number is likely to be an underestimate because it is based on women who give Irish addresses and does not count those who go to other countries, like France and the Netherlands. Besides abortion being illegal, there are strict information laws covering what you can and cannot say about abortion to a third party, in public or private. The text of the Abortion Information Act is available at: http://tiny.cc/I6bRA  A very good account of the laws and how they have evolved is available at:

www.safeandlegalinireland.com/sl_law.html

In the Republic and the North, there are very strong and active anti-abortion movements and small (but active) pro-choice groups. “Abortion” is, socially, the “A word” – not to be spoken about in company. The main pro-choice groups in the Republic are Choice Ireland, a feminist activist group (visit: www.choiceireland.org ) and Safe and Legal, (www.safeandlegalinireland.com/), while in the North there is the Alliance for Choice: http://allianceforchoiceni.org/

CURRENT ISSUES:

1. ABC CASE: What’s known as the ABC case is due to be heard in the European Court of Human Rights in Strasbourg on 9 December. The case has been taken by three women from Ireland (A, B and C) and focuses on whether their human rights were violated because they were not able to obtain abortions in Ireland (they traveled to England). According to a report by the Association for Women’s Rights in Development, one of the women had a high risk of an ectopic pregnancy; another had undergone chemotherapy for cancer treatment and sought but could not find a doctor willing to tell her whether her life would be at risk if she continued the pregnancy and how the fetus might have been affected; the third had four children in foster care because of problems with alcoholism. She was unmarried, unemployed and living in poverty. The facts of the case are available here: http://tiny.cc/UDG6f

2. ROGUE AGENCIES: One pro-choice campaign in the Republic has been against rogue counseling agencies that are unregulated, that advertise in the Irish equivalent of the Yellow Pages, and that give women false information in an effort to dissuade them from abortion. This has been a focus of Choice Ireland, which has secured a hearing on the matter in front of a Parliamentary (Oireachtas) committee, scheduled for early December. For more on the group’s campaign, visit: www.choiceireland.org (You can donate to the group there, too.)

3. DEVOLUTION IN THE NORTH: Northern Ireland is exempt from the 1967 UK Abortion Act, and all attempts to extend the Act to N.I. have failed, including one in 2008-9 by Labour MP Diane Abbott. Control over justice and policing is expected to be handed over to the Stormont Assembly in the North (from Westminster) soon, and when that happens, pro-choice supporters expect there to be even less likelihood of change because, as one Belfast columnist wrote, “Once justice is devolved, women seeking the right to choose will be left at the mercy of the DUP and Sinn Fein, both of which, whatever their disagreements on other matters, are unlikely to budge on abortion.” To read that excellent article, “Why have we one rule for abortion in Lusaka and another in Lisburn?” in full, visit: http://tiny.cc/Adxya

4. ILLEGAL ABORTION: There is anecdotal evidence of a rise in illegal abortions in Ireland, but no hard statistics. The group Women on Web, which distributes the abortion pill by mail to women who meet its criteria, warns women from Ireland: “Sorry, the medical abortion can not be provided to Ireland. Recently some packages have been seized by the Irish Medical Board and we cannot guarantee that the package will get to you safely.” In addition, migrant women, women seeking refugee status and illegal immigrants cannot go abroad for abortions because of difficulties re-entering the country (also frequently for financial reasons). And, increasingly, women who are citizens and legal residents of Ireland cannot afford the cost of travel to a UK clinic, which can cost around 2000 euro.

Australia

Marie Stopes International is now providing an early medical abortion service in their Australian clinics for pregnancies up to nine weeks. Jill Michelson, General Manager, Operations presented an update at the Mifepristone in Australasia Conference and commented upon the acceptability and success of the new service.

In Queensland Tegan Leach (19) and her boyfriend Sergie Brennan (21) appeared again in the Cairns Magistrates Court for a committal hearing and on 11 September the magistrate Sandra Pearson decided that the case will go to trial, Tegan on a charge or procuring an abortion (penalty up to seven years in jail) and Sergie on a charge of supplying drugs to procure an abortion (penalty up to three years).  Professor Caroline de Costa spoke at the Mifepristone in Australasia conference about the situation in Queensland and the need for reform of the outdated laws.

On 31 August Premier Anna Bligh proposed an amendment to correct the anomaly in Section 282 of the Criminal Code specifying surgical (but not medical) in defence of a lawful abortion. It was passed on 2 September with both the government and the opposition supporting the change. For more information go to www.prochoiceqld.org.au

On a positive note, in August, Australia revoked a ban that had been in place for 13 years against providing overseas aid for abortions. Funding is now permitted in countries where abortion is legal up to 20 weeks gestation. The ban was introduced during the term of conservative Prime Minister John Howard.

U.S.A.

The most bizarre proposal to emerge from Colorado is a campaign to define eggs as people! Yes, not just giving constitutional rights to a fetus or an embryo but to a single cell. In 2008 Colorado was the first state legislature to debate an amendment giving personhood status to a fertilised egg. The amendment was comfortably defeated but this has not deterred campaigners concerned about where reproductive technologies may lead. An organisation Personhood USA has been leading petition drives not just in Colorado but in Mississippi, Montana and Nevada. If ever passed such legislation would have far reaching consequences, not only impacting on embryonic stem cell research and in-vitro fertilisation programmes but also jeopardising the use of contraception and abortion. The underlying goal is to ban all abortion and in this respect it is very closely aligned to the strategies of anti-abortion groups in NZ. Recently there has been a proliferation of such groups attacking Family Planning for its initiative in planning to provide early medical abortions in its clinics. Protests, petitions and the language used have been imported from the USA.

There was an expectation that following the approval of mifepristone in 2000, abortion would become more accessible particularly in rural areas. New research from the Guttmacher Institute suggests that although the use of mifepristone has become widespread and has contributed to a shift toward earlier abortions, it has not significantly improved the geographic access to abortion services. This is something that NZ must take on board as mifepristone use increases here.

Canada

In September new stringent rules for clinics were to be introduced in Quebec but because of the threatened closure of clinics the Health Minister was forced to reconsider the plans.

Spain

There have been marches in the street with the Catholic Church opposing liberal law changes.