On 1 April 2011 Save the Children launched a campaign to find the missing midwives.

Save the Children’s recent research suggests that globally we need 350,000 midwives, and that this shortage of skilled birth attendants means as few as 6% of women in some developing countries have access to skilled birth attendants. As a result there are as many as 1,000 women and 2,000 children dying daily, many of whose lives could be saved if a trained midwife was present.

350,000 seems a remarkably small number and an achievable target. However, when you consider that the UK itself is also short of midwives, perhaps it is not a surprise that this gap has not been as easy to bridge as at first it seemed. As birth rates rise in the UK, we seem to be training fewer midwives. Most midwives I know work in understaffed, over stressed units, and yet still manage to deliver a generally high standard of care that ensures that not only are the vast majority of British babies delivered safely, they are also delivered in a way that makes for a meaningful and happy experience for the mother. One wonders for how much longer though, as we fail to train new midwives and support effectively those already working in the profession. As DFID gets behind the Save the Children campaign, it is worrying that other parts of the national and devolved governments are at best playing catch up and at worst reducing the numbers of midwives in this country!

However, in many parts of the world, there is no such provision. Partly this is an issue of poverty, and partly a mixture of cultural and political values that do not prioritise motherhood or the life and health of women and children. As we at CMF highlighted in our submission to DFID’s maternal health strategy consultation, it is only by addressing these issues, as well as the provision of trained midwives, obstetricians, and appropriate medical supply chains etc., that we can turn around the gross inequality in maternal health and survival around the globe.

It is ironic, on Mother’s Day, to consider a world that really does not value mothers and motherhood. We live in a culture here in the UK that has such a disordered sense of human value that it does not train enough midwives, but instead prioritises free prescription of abortifacient post coital conception. In the process we are failing to address the deeper issues of fractured relationships and disordered sexuality that leads us to have one of the highest teen pregnancy rates in the Western world. And as MPs seek to increase the amount of information, counselling and professional support being provided to women seeking an abortion, they are attacked for trying to harm women. In other parts of the world a man will let his wife die rather than incur the cost of getting her to a hospital – other wives are always available, while his government will not put any money into training midwives who could have helped her deliver her child more safely at home. It is a sobering thought, as we celebrate our mothers this Sunday. We need to do more than give a few gifts to say thanks to our mothers; we need to take action to seek to see motherhood properly supported around the world, and here at home.

To sign the Save the Children petition to the UK Development Secretary and support the global drive for more midwives click here.

Posted by Steve Fouch

CMF Head of Allied Professions Ministries

New figures from The Lancet reveal the tragedy of the scale of stillbirths, estimated at around 3 million worldwide, every year; or more than 8,200 stillborn babies a day.

This vast number eclipses deaths from AIDS/HIV and many other diseases that get far more money. Perhaps not surprisingly, 98% of these are in low- and middle-income countries, which compounds the tragedy as most of these stillbirths would not occur if basic and comprehensive emergency obstetric care were as available, and as good, as in high-income countries.

Numbers on this scale can sometimes hide the personal impact and grief that each one of these stillbirths will have caused for those involved.  Indeed, as one Lancet article comments:

‘One of the most devastating myths that surrounds stillbirth is that women who are accustomed to high infant mortality and high rates of stillbirth somehow feel the individual loss of a wanted pregnancy less than women living in high-income countries.’ http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60279-1/fulltext

Not only do they feel the loss of the pregnancy, but they also often bear an additional, if unwarranted, sense of responsibility or shame and, at times, blame from their husbands.

The controversy of these figures lies not just in the scale (though that is of course an important issue of inequity and resource provision) but also in the fact that many of these deaths are being ignored.  They are being ignored – The Lancet claims – because of the politics of abortion.

The Lancet series on stillbirths highlights how this global public health problem fails to feature in any major global or national health targets and commitments:

‘The mother’s own aspiration of a liveborn baby is not recognised on the world’s health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals…Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby.’http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62232-5/abstract

So why is stillbirth ‘one of the most shamefully neglected areas of public health’?

One of the reasons it remains ‘in the shadows’, as Lancet editor, Richard Horton, states, is because of pro-abortion sentiments. Although, he says, the definition recommended by the WHO – a baby born with no signs of life at or after 28 weeks’ gestation – is sensible, since few babies born before this age are likely to survive in low-income countries, some, however, do survive after as few as 22 weeks in high-income countries.  Therefore:

‘Not to count as a stillbirth the death of a baby born at between 22 and 28 weeks’ gestation, or earlier, would be to deny many parents the gravitas their grief demanded. When one considers that in many countries abortion is allowed up to and sometimes beyond 24 weeks, one can begin to understand authorities’ reluctance to pursue the point. In reality, however, the two issues are completely separate. Every woman has the right to a safe abortion, should that be necessary, but she also has the right to have the death of her baby counted in the process by which countries monitor and improve the indicators of health.” http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60098-6/fulltext

Clearly Horton supports the availability of abortion and sees no dilemma in this, however he is prepared to stand up to the very powerful pro-abortion lobby when he believes the evidence demands it. It is not the first time that Horton has taken on this lobby.  Some may recall that The Lancet challenged WHO data and methodology last year on maternal death statistics, which were being used to promote abortion worldwide. He was duly attacked for it, but was ultimately vindicated when the WHO estimates were quietly re-written and lowered, in line with the Lancet evidence. (see previous CMF blogs on gender imbalance and maternal mortality)

Horton will undoubtedly face challenges with this series on stillbirths. One linked article suggests that a primary solution lies in improving women’s rights and access to reproductive and sexual health services ie. more family planning and abortion on demand. However The Lancet rightly calls for prevention and treatment of infection and improved obstetric care, along with recognition and targeting of the problem, not for more abortion:

“We call for inclusion of stillbirth as a recognised outcome in all relevant international health reports and initiatives. We ask every country to develop and implement a plan to improve maternal and neonatal health that includes a reduction in stillbirths, and to count stillbirths in their vital statistics and other health outcome surveillance systems.” http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62235-0/abstract

Every stillbirth is a tragedy. It is sad that recognition of this tragedy has become mired in controversial abortion politics. Let’s hope that these births are no longer ignored as a result.

Posted by Philippa Taylor

CMF Head of Public Policy

The charity Life has been included on a new government sexual health forum – amidst an outcry of protest. It’s a predictable reaction – but sadly misguided.

Life supports vulnerable pregnant women, focussing on crisis pregnancy counselling, education, practical provision (like free baby clothes), and homeless pregnant women. Its mission is ‘to uphold the utmost respect for human life from fertilisation (conception) until natural death’. Stuart Cowie, Life’s head of education responded to its inclusion by saying: “We are delighted to be invited into the group, representing views that have not always been around on similar tables in the past.”

But the Chief Executive of the British Pregnancy Advisory Service (BPAS), has expressed surprise that a group opposed to abortion would be invited to such a forum. It itself is not a member of the new forum (having been part of a previous group which the forum replaces). Meanwhile, former Liberal Democrat MP Dr. Evan Harris is also opposed, saying the inclusion of Life could ‘prevent the advisory panel having frank and open discussions because you have a group there that is committed to opposing current policy.’

It’s worth noting that the Department of Health emphasised the need for a variety of views to be represented, recognising that Marie Stopes (an abortion provider like BPAS) is a member.

Encouraging debate

Surely the very point of a ‘forum’ is to allow an exchange of views? How can this happen if organisations or individuals who do not ‘toe the line’ over current policy are excluded? The fact that debate has been stifled in the past is not justification for doing so now or in the future.

The latest abortion statistics show that a quarter of abortions in the under-25s took place in those who had undergone a previous termination of pregnancy. Another year-on-year rise in the number of abortions carried out in the UK contributes to a more significant long-term trend, with an 8% rise in abortions over the last decade.

Unsurprisingly, pro-choice groups have called for greater investment in contraceptive services – but even if this happens, will the number of abortions really fall? Wider access to contraception doesn’t seem to have had an impact on the figures over the last few years.

A change in policy will never come about if only groups who support the current policy are allowed to participate in discussion. This reason alone is sufficient to welcome the Department of Health’s inclusion of a group such as Life, and to hope that other such fora also hear a wider range of views in future.

Posted by Laurence Crutchlow

CMF Associate Head of Student Ministries

A UN report published yesterday (23 June) suggests that not only is sex selective abortion becoming a growing trend in many Asian countries, it is also having huge health and social consequences for women and girls.

Sadly, this is not news. Over twenty years ago, the Indian writer and thinker Amartya Sen wrote about the missing millions of girls in India, while China’s ‘One Child’ policy is widely thought to have led to a growing imbalance in the number of boys to girls.  In these two largest nations on earth (together accounting for between a quarter to a third of the world’s population) there has always been a deeply entrenched cultural, social and economic bias towards boys rather than girls.

Historically, in many nations this has meant that girl babies would be more likely to be neglected, killed or left to die in preference to male children. But the arrival of ante-natal screening technologies and medical abortion seem to have accelerated this trend. In some parts of India and China there are as many as 120-130 boys for every 100 girls.

This bias towards boys is deeply entrenched, and although sex selective abortion is increasingly outlawed, the reality is that these laws are flouted and broken widely. The long term consequences of this are hard to predict. However, any society where there will be a lack of marriageable females and a surplus of males is storing up a whole mass of social and cultural troubles for itself. According the UN, one manifestation already being seen is the trafficking of women to correct the gender imbalance – often forcibly.

Another disturbing fact is that the trend towards sex selection is strongest amongst the urban middle and upper classes – where poverty is not the driving force.  Poor villagers have less access to antenatal screening and medical abortion, but tend to take less care of their female children (stopping breast feeding earlier, giving smaller portions at meal times, less access to good clothing or education), and have more children to ensure a male child is born – each subsequent pregnancy increasing the health risks for the mother and subsequent children.

And even amongst the rich, evidence from here in the West is mounting that abortion can have long term mental health risks, can increase the risks of low birth weight in subsequent children and that there is a possible link to increased risks of breast cancer. These risks accrue the more terminations a woman has.

The UN rightly points out that more laws do not make much difference, but also bends over backwards to say that there should be no restriction in the provision of abortion services (a bit of UN double think I fear – surely access to the medical technology has been part of the problem, so surely there needs to be tighter regulation on its misuse as part of the solution?)

However, the UN does rightly argue for a wider engagement in education and mobilising civil society to change attitudes.  This is to be applauded, as we know that this can work (e.g. the impact of joint government, church and voluntary sector responses to HIV prevention in Uganda and Senegal).

And this is an area where all faiths tend to agree. For instance, the Qu’ran speaks out specifically against female infanticide (Sura 81v8 & 9), while the early Christians were involved in caring for infants who had been abandoned at city gates to die, setting up the first ‘foundling homes’.  This is an area where churches, mosques and other faith communities can be mobilised effectively to challenge attitudes in wider society.

Nevertheless this bias towards boys remains one of the great obstacles to women and newborns enjoying better health and greater longevity, slowing down progress to the fourth and fifth Millennium Development Goals. Furthermore it shows that the advent of modern medical technologies can exacerbate rather than improve health problems where social attitudes and values do not change.

Posted by Steve Fouch

CMF Head of Allied Professions Ministries

Many people assume that women considering abortion have access to independent information and advice. In fact there is no legal guarantee that they do.  Where counselling is available, it is often given by the very same private providers that carry out abortions and gain financially from them!

Vulnerable women frequently find themselves on a conveyor belt that leads inexorably towards abortion, with little or no opportunity or time to consider other options, or to be fully informed of any of the risks associated with abortion.

Women cannot be sure that they are getting independent information and advice when it comes from organisations that rely heavily on charging the NHS for each abortion they carry out, and who therefore have a vested financial interest. The so-called independence of counselling by abortion providers will inevitably be compromised by a drive to encourage a decision for abortion. This conflict of interest is like a pension provider giving pension advice. As Rt Hon Frank Field MP, who has tabled the amendment, says: “In the huge scandal of pension mis-selling, Parliament quite rightly took the decision to separate advice from the process of selling. We wish, quite simply, for this basic principle to be applied to the provision of NHS abortions.”

Field, along with Nadine Dorries MP, have together put down amendments concerning the provision of independent information for women considering an abortion, which will be debated next Tuesday, 6 September.  The amendments are tabled to the Health and Social Care Bill and do two things:

Firstly, GPs would be required to ensure that woman considering abortion have access to proper advice, information and counselling. Secondly, they would guarantee that those providing help do not have a vested financial interest in providing abortion.  In other words, the amendment would remove the financial conflict where private abortion clinics currently provide both NHS counselling and abortions. Instead, advice, support and counselling would be available to women via their GP practice, in their own community, before they visit the abortion clinic.

Abortion always generates strong feelings and debate and, as expected, there is widespread media interest in an abortion vote in Parliament.  Despite fear mongering in some of the media about delays to abortion provision counselling would not be made compulsory and access to independent counselling would only need to be offered to women under these amendments. But at the moment, as Dorries says, almost zero counselling is available for any woman presenting at her GP practice with a crisis pregnancy and the little support that is available is mostly provided by the abortion provider.

This has to change. The drive to make abortion swift and easily accessible has meant that many women enter the process confused, without proper information, and unaware of any physical or mental health consequences (despite clear evidence that abortion is linked to mental health problems for some women, along with an increased risk of a later pre-term birth).

The conveyor belt does not stop and make time for information provision on such risks.

Encouragingly, and as we have noted elsewhere, the government has already recognised the need for independent counselling and information on risks of abortion. For example, the Minister for Public Health, Anne Milton has stated that: “women should be given access to tailored, appropriate and impartial advice on their pregnancy options.”  Earl Howe has made similar commitments.

There are still unanswered questions about how to ensure that counselling is truly independent, and who will provide it, but for now there is an urgent need to support moves that will start the process towards this provision. And whilst the government has accepted the need for independent counselling in principle, it is vital that as many MPs as possible also back this.

The voices of health professionals will surely carry weight in this debate, so we strongly encourage as many people as possible to write to their MP prior to the debate on Tuesday.  Please urge your MP to support moves to guarantee that women considering abortion have full and free access to independent information, advice and counselling.

For more information about the amendments and what you can do, see the Right to Know Campaign here: http://righttoknow.org.uk/

Posted by Philippa Taylor

CMF Head of Public Policy

Several stories in recent days illustrate the rather confused priorities of the British government towards maternal health.

Yesterday the Royal College of Midwives reported that parts of England are facing shortages of midwives of between ten and 41 per cent – set against the background of a 22% rise in birth rate over the last two decades.  The RCM is concerned, quite rightly, that this puts the health and well being of mothers and babies at risk, with staff to stretched to do a good job and provide the level of care that they would wish to, or that mothers need.  Interestingly, Scotland, Wales and Northern Ireland are not facing this gap. It is not a lack of trained midwives that is necessarily the problem (although training places are being cut, so we are storing up long term problems); at the moment this imbalance is purely down to the investment in midwifery services by different regions of the NHS in England.

David Cameron famously said that he was committed to improving midwifery services before the election, and in particular wanted to increase midwife numbers by 3,000. It seems that in England at least, the opposite seems to be happening, and the RCM are now campaigning for a further 5,000 midwifery posts.

At the same time, the WHO also reported that deaths in under fives were decreasing in the developing world, with twelve thousand fewer children dying each day globally than a decade ago. And today, the Lancet reports that in China, infant mortality rates have halved over the last decade due to an increased access to hospital based maternity services.

Reports from last year also show that there has been a marked improvement in the rates of maternal mortality in the developing world over the last two decades.  We have not solved the problems, but we are making progress.  Yet at the same time, here in the UK we are in real danger of stepping backwards.  As the RCM points out, midwives are the backbone of our maternity services, and without them women are not getting the care they need to give birth safely.

It is right that we ring fence development funding and prioritise maternal and child health improvements in the developing world, because increasingly the evidence shows that this kind of aid and development is having a real impact on the lives and well being of the poor.  But it cannot be right that at the same time we are cutting back on maternity services here in the UK and putting mothers at risk in this country.  To be sure, the risks an English mother faces are not even remotely on the scale of those faced by a mother in, say, Afghanistan, but they are no less real and no less deserving of our full commitment and funding – two commodities that seems to be in short supply right now in Britain.

Posted by Steve Fouch

CMF Head of Allied Professions Ministries

The fifth Millennium Development Goal (MDG) put forward by the United Nations (MDG-5) proposes to reduce the world’s maternal mortality ratio by 75%, by 2015.

But what is the best way of doing this?

International programmes sponsored by the UK and US governments, and delivered under the auspices of international organisations like the UNFPA (UN Population Fund) and IPPF (International Planned Parenthood Federation), focus on the provision of contraception and ‘safe’ abortion as key priorities.

However a new 50 year follow-up study from Chile has literally blown that hypothesis out of the water and demonstrated that the key determinant of maternal mortality is actually the educational level of women.

Furthermore, one of the most significant findings is that, contrary to widely-held assumptions, making abortion illegal in Chile did not result in an increase in maternal mortality. In fact, after abortion was made illegal in 1989, the MMR continued to decrease from 41.3 to 12.7 per 100,000 live births (69.2% reduction).

The result is that Chile is now doing better with maternal mortality than the United States.

Chile offers an opportunity to investigate the influence of these determinants on maternal mortality trends. Not only are large time series of vital and socioeconomic data available for this country that are of similar quality to those of developed countries, but legislation prohibiting therapeutic abortion was passed in 1989.

As a result, data from Chile provide a rare and unique natural experiment to evaluate the influence of population factors, the legal status of abortion and other historical policies on maternal mortality trends since data are available before and after interventions were implemented.

Another recent report has shown how Ireland and Northern Ireland benefit significantly from their near complete ban on abortion in a number of ways.

The report, ‘Ireland’s Gain’, links Ireland’s low abortion rate to low incidences of breast cancer and comparative good mental health among women when compared with those in England, Scotland and Wales.

The implications for international policy are clear, but will the lavishly funded birth control and abortion industry take note?

I’ve reproduced below the press release from AAPLOG about the Chilean study which gives more of the detail.

Chile Outperforms US and Dramatically Reduces Maternal Deaths by Increasing Women’s Educational Level

A scientific analysis of 50 years of maternal mortality data from Chile has found that the most important factor in reducing maternal mortality is the educational level of women.

‘Educating women enhances women’s ability to access existing health care resources, including skilled attendants for childbirth, and directly leads to a reduction in her risk of dying during pregnancy and childbirth,’ according to Dr Elard Koch, epidemiologist and leading author of the study.

The research entitled ‘Women’s Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: a Natural Experiment in Chile from 1957 to 2007’ was conducted on behalf of the Chilean Maternal Mortality Research Initiative (CMMRI) and published in the Friday, May 4 issue of PLoS ONE.

Using 50 years of official data from Chile’s National Institute of Statistics (1957-2007), the authors looked at factors likely to affect maternal mortality, such as years of education, per capita income, total fertility rate, birth order, clean water supply, sanitary sewer, and childbirth delivery by skilled attendants. They also analyse the effect of historical educational and maternal health policies, including legislation that has prohibited abortion in Chile since 1989, on maternal mortality.

During the fifty-year study period, the overall Maternal Mortality Ratio or MMR (the number of maternal deaths related to childbearing divided by the number of live births) dramatically declined by 93.8%, from 270.7 to 18.2 deaths per 100,000 live births between 1957 and 2007, making Chile a paragon for maternal health in other countries. ‘In fact, during 2008, the overall MMR declined again, to 16.5 per 100,000 live births, positioning Chile as the country with the second lowest MMR in the American continent after Canada and with at least two points lower MMR than United States’ said Koch.

One of the most significant findings is that, contrary to widely-held assumptions, making abortion illegal in Chile did not result in an increase in maternal mortality. In fact, after abortion was made illegal in 1989, the MMR continued to decrease from 41.3 to 12.7 per 100,000 live births (69.2% reduction). ‘Definitively, the legal prohibition of abortion is unrelated to overall maternal mortality rates’ emphasized Koch.

The variables affecting this decrease included the predictable factors of delivery by skilled attendants, complementary nutrition for pregnant women and their children in the primary care clinics and schools, clean facilities, and fertility. But the most important factor and the one which increased the effect of all others was the educational level of women. For every additional year of maternal education there was a corresponding decrease in the MMR of 29.3 per 100,000 live births.

The picture for Chile includes a transition of leading causes of death along with an accelerated decline of fertility and delayed motherhood. Koch explained that direct causes –those directly attributable to pregnancy condition– were the rule before 1990, but from then, indirect causes –ie. non-obstetric chronic conditions such as hypertension and diabetes among others– rise as the most prevalent, hindering the decline on maternal mortality.

‘This study uncovers an ongoing “fertility paradox” in maternal health: education is the major modulator that has helped Chile to reach one of the safest motherhood in the world, but also contributes to decrease fertility, excessively delaying motherhood and puts mothers on risk because of their older age.’ Thus, an emerging problem nowadays ‘is not a question of how many children a mother has, but a question of when a mother has her children, specially the first of them’ concluded Koch.

Press Release from American Association of Pro Life Obstetricians and Gynecologists (AAPLOG)

A more complete statement on the study by the study’s author is available here

Conclusion by Elard Koch, the main author

Taken together, the Chilean natural experiment over the last fifty years suggests that the progress on maternal health in developing countries is a function of the following factors: an increase in the educational level of women, complementary nutrition for pregnant women and their children in the primary care network and schools, universal access to improved maternal health facilities (early prenatal care, delivery by skilled birth attendants, postnatal care, availability of emergency obstetric units and specialized obstetric care); changes in women’s reproductive behaviour enabling them to control their own fertility; and improvements in the sanitary system ie. clean water supply and sanitary sewer access. Furthermore, it is confirmed that women’s educational level appears to have an important modulating effect on other variables, especially promoting the utilization of maternal health facilities and modifying the reproductive behaviour. Consequently, it is proposed that these strategies outlined in different MDGs and implemented in different countries may act synergistically and rapidly to decrease maternal deaths in the developing world.

Posted by Dr Peter Saunders

CMF Chief Executive

Last week saw a major summit in London on the role of family planning in global development, hosted by the British Government’s Department for International Development (DFID), and instigated by the Bill & Melinda Gates Foundation. It was primarily a pledging conference, with the great and the good from many nations taking it in turns talking about the importance of family planning to allow women to space their children and manage the size of family as a means to achieving healthier families.  And it worked, on the funding front at least, with a total of an extra $4.6 billion pledged for family planning services worldwide by 2020 (the target was $4 billion), split between developing country governments ($2 billion), and Western donors ($2.6 billion).

Melinda Gates, who fronted the summit on behalf of her and her husband’s philanthropic foundation, was keen to avoid controversy.  She sought to allay the old fears of top down, Western driven, coercive population control and widespread promotion of abortion, stressing that these were not part of the agenda.  However, commentators noted that many of the main NGOs and UN bodies involved have been linked with the former and have all been involved with the provision of abortion services.  And there is big money for the pharmaceutical industry in providing contraception – an industry the Financial Times reckons to be worth $17 billion in the next three years. So controversy was never far below the surface, which is why the whole topic has not really been high on the development and international health agendas for decades.

Another aspect of the summit was the side events, where various sections of civil society were able to discuss the issues on the ground.  One of these looked at the role of family planning in HIV prevention, and issued a call to action to empower and enable women to make informed choices about contraception and HIV prevention (including prevention of mother to child transmission of HIV).  As one of the presenters noted, if we want to see Millennium Development Goals 4, 5 & 6 reached, then linking HIV prevention and family planning makes sense. However, abortion was also very much on the agenda of this call to action, sadly making it a no-go area for most faith groups who had common cause with its core aims.

Indeed, many also noted that there was either scant mention of the role of faith groups in family planning, or outright criticism of their role and stance around the issue – not always without reason.  Nevertheless, the lack of space for faith in the main summit led to another side event on the following day that focussed on faith based responses to family planning.

One of the main comments to come out of this side event was that the rhetoric from the stage at the summit had been very much on a rights-based approach to family planning, rather than a community based approach.  In other words, very much from a Western individualistic human rights vantage point, rather than a more communal, human dignity and community rights based approach that is more common in most developing world cultures.

Despite the human rights rhetoric though, the actual proposals coming from the main summit seemed very much supply orientated, rather than focusing on community demand. It was about meeting the funders’ and suppliers’ objectives rather than relying on local communities’ own values and priorities around family planning for their own needs.  Instead, most of the Faith Based Organisations (FBOs) at the meeting were seeking to work to local agendas rather than those driven by governments and major donors.   Many voiced concern that the drugs and medical technology industries were very much in evidence, and there was a worry that their priorities were given too much prominence.

Another area of concern was the lack of attention to strengthening (and training) the health workforce. As the faith sector was being demonised as part of the problem rather than as a resource, the feeling was that the summit had missed the target.  However, it is worth noting that this is the same thing that happened 30 years ago with HIV, especially with regards to the marginalization of faith.  We in the faith-based sector need to remember the lessons of those years – that it is the quality of what we do that earns us a voice, rather than the quality of our rhetoric or by shouting from the sidelines.

The problems raised by speakers at the summit seem to have been mainly with religious leaders’ statements (or silence) on contraception rather than with the FBOs that are actually working on the ground.   We saw many excellent presentations of work being done by different FBOs that engaged with the faith of local communities, included religious leaders, and worked from Scripture to help put family planning into the context of the beliefs and values of the community.  It was noted that just supplying contraceptives and money for training was not enough – it is about long term engagement with, and participation in, the community, helping them to address their own needs and priorities for health and development, and so helping them to choose how to plan their own families appropriately to their own priorities.  It was noted that research suggests that being part of any faith community has no substantial impact on the use of contraception by women, but the support of congregational faith leaders does have a significant impact on the use of birth control.

There was some discussion about different approaches to the subject within the Catholic Church and development agencies, noting that it is more nuanced and diverse than is often thought.  There was also a positive response from a DFID representative who said that they are keen to work with faith groups, who they see as part of the ‘enabling environment’ that is needed to effectively and appropriately introduce family planning.  We hope that this is a good example of DFID’s new principles on working with faith being put into action.

Of course, there are differences on many issues.  Not least of which is the core question of whether family planning is about medical contraception, including abortion, or about wider development, education and health that includes a range of medical and non-medical methods of birth control?

Many agreed that the main summit was a move to get consensus rather than drive one, ideologically polarised viewpoint or another, but recognised that it would never be easy to achieve as there was no simple consensus.  That does not mean that we do not work together to find areas of common agreement.  But above all else, with the renewed global interest in family planning, FBOs already doing good work on the ground have a chance to shape global strategies and policies positively, if we are willing to enter into dialogue with the wider development and global health community – however hard or uncomfortable this may make us feel. This is an area from which Christians working in international health and development cannot shy away in the years ahead.

Posted by Steve Fouch

CMF Head of Allied Professions Ministries

The jury in the Savita Halappanavar inquest has returned a unanimous verdict of death by medical misadventure.

Savita Halappanavar (pictured), 31, was an Indian woman who tragically died in Ireland from overwhelming infection after allegedly being denied an abortion.

Her case has been seized upon by the pro-choice lobby as grounds for liberalising Ireland’s abortion law.

Savita was 17 weeks pregnant when admitted to the University Hospital Galway on 21 October 2012 with an inevitable miscarriage.

At that time a fetal heart beat was detected and doctors opted not to end the pregnancy by inducing labour but instead waited for her to deliver naturally.

Her baby was born dead three days later on 24 October.

Savita died from multi-organ failure from septic shock due to an E coli infection on 28 October, four days after her baby’s birth.

The coroner, Dr Ciaran MacLoughlin, said the verdict of medical misadventure did not mean that deficiencies or systems failures in University Hospital Galway necessarily contributed to Mrs Halappanavar’s death; these were just findings in relation to the management of her care.

The chief operating officer at the Galway Roscommon Hospital Group, Tony Canavan, acknowledged that there were lapses in the standards of care provided to Mrs Halappanavar and said that deficiencies identified during the inquest would be rectified by the hospital.

Leading obstetrician Peter Boylan outlined a number of deficiencies in her care, but stressed that none on its own was likely to have resulted in Mrs Halappanavar’s death.

The coroner’s nine recommendations  (summarised below) were strongly endorsed by the jury.

The key recommendation read as follows:

‘The Medical Council should lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which would remove doubt and fear from the doctor and also reassure the public. An Bord Altranais should have similar directives for midwives so that the two professions always complement one another.’

The other eight recommendations involved improving hospital systems and procedures.

There are four key questions in this tragic case:

If the doctors had intervened earlier to induce labour when the baby’s heartbeat was still present would Savita have died? Quite possibly not, but at that stage there was no suggestion that her life was in danger.

If they had acted more quickly to diagnose and treat her E coli infection might she have been saved? Possibly. There were several acknowledged errors and omissions made in her care but it is impossible to prove that these led to her death.

Did Savita die because of the Irish abortion law? No, because Irish law already allows abortion when there is a risk to the life, as distinct from the health, of the mother.  Making this judgement, however, sometimes requires considerable skill and experience, which is why clearer guidance from the Irish Medical Council, within the existing law, is to be welcomed.

Does the Irish abortion law need changing? No. As I have previously argued in much more depth on this blog, Savita’s tragic death is not a reason to change the law.

Ireland remains one of the safest places in the world to have a baby. Its maternal mortality rate is just six deaths per 100,000 live births. This compares with 12 in the UK, 15 in the US and 200 in India.

As there are about 75,000 live births a year in Ireland this means that there is an average of just four maternal deaths per year from all causes.

Savita’s death was indeed a tragedy and there was medical misadventure involved in her care, but we should be very wary of knee-jerk legislation. It is far better to handle exceptional circumstances like this by way of guidance from the Medical Council.

Ending a pregnancy to save the life of a mother by inducing labour when the baby is too young to survive outside the womb is sometimes necessary in extremely rare circumstances.  But this is already legal in Ireland.

Changing the law in Ireland to that of the UK would not save any mothers’ lives but instead would lead to around 11,000 more abortions annually.

The baby in the womb is the most vulnerable of human beings, worthy of wonder, respect, care and protection. The law should reflect that fact whilst allowing intervention to save one life (the mother) in cases where not intervening would mean that two lives (both mother and baby) are lost.

Summary of Coroner’s recommendations (from the Independent):

* The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;

* Blood samples are properly followed up;

* Protocol in the management of sepsis and guidelines introduced for all medical personal;

* Proper communication between staff with dedicated handover set aside on change of shift;

* Protocol for dealing with sepsis to be written by microbiology departments;

* Modified early warning score charts to be adopted by all staff;

* Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;

* Medical notes and nursing notes to be kept separately;

* No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.

Posted by Dr Peter Saunders

CMF Chief Executive

Despite my determination a few years ago not to be a GP with a Women’s Health interest that’s exactly what I’ve found that I love!  Having exhausted the UK Diplomas and Letters of Competence and with a long-standing interest in working in developing nations, I wondered just how much difference a GP can make in these settings. So I took three months off work and went to Liverpool to do the Diploma in Reproductive Health in Developing Countries (DRH).

So what is the DRH?

The DRH is a 12-week program run each year between January and the end of March and organised by the Maternal & Newborn Health Unit at the Liverpool School of Tropical Medicine, in partnership with the Royal College of Obstetricians and Gynaecologists.

It is designed to equip a variety of health professionals, from program developers to doctors, to understand some of the complexities and challenges of providing quality reproductive healthcare to developing nations,. It examines what kind of interventions have evidence to support improvement, encompassing everything from family planning services to post-natal care .  The DRH is the only course of its kind – hence people travel from all over the world to undertake it.

What did I learn?

Loads.  On the academic side, I can now tell you about strategies for improving aspects of reproductive healthcare; everything from stemming the tide of STIs, providing evidence based obstetric care, initiating quality improvement activities to tackling issues of sexual and gender based violence…but as with many things, what I gained from the course was as much about the people I met and the relationships built as writing papers and sitting exams.

There were 15 students on the course – from all disciplines, ages, backgrounds, religions and countries; many of them will take back what they have learnt directly into their districts and hospitals, being agents for change. Each had stories to tell and a wealth of experience whilst being willing to learn – they were inspiring to listen to and a privilege to spend time with.  It was also an environment where no conversation was off limits so matters of faith, ethics and conscience echoed around wherever we met – often in quite heated and passionate debate.

Faith-based organisations and faith-based challenges

It was interesting to hear different understandings of the place of faith in medicine, and to see how this played out both in the classroom and in the places where participants are working. One example of this was a lady who works for a faith-based organisation trying to set up what we would understand as a family planning clinic in an environment where it is perceived that ‘God determines how many children and when.’ She is desperately trying to reduce the maternal death rates in very young primagravidas, grand multips and those with significant chronic illness, while providing contraceptive options that would be acceptable to their faith and their husbands.

As expected there are no easy answers! The more we delved, explored and debated tools and solutions, the more complex things became – on the one hand we began to have a structure of how to tackle certain problems and on the other we became more aware of just how difficult it is to implement lasting and life-giving change to those who need it the most. The importance of understanding the convoluted and multifaceted nature of different cultures is paramount in achieving any enduring improvement.  The dilemmas and difficulties are endless, but those who hope in Jesus as their Saviour are not prepared to give up the fight!

Who should do the DRH?

This is quite a specific qualification but if you intend to work in this area you may find that it provides you with a very different skill set to the traditional tropical medical diploma. It also gives an opportunity to do some specific research into an area of interest with a literature review – great if you know where you are going and want to work out how best to help and not hinder.

Want to find out more? Contact me at chollingsworth@doctors.org.uk

CMF’s Developing Health Course is coming up – June 30- July12, with two excellent days on Women’s Health…could be a great forerunner to the next DRH!

Posted by Dr Claire Hollingsworth, CMF member

The question of whether restrictive laws on abortion lead to fewer maternal deaths, or more maternal deaths, is hotly debated.

Those who are ‘pro-life’ and want to see more restrictive abortion laws say that fewer abortions leads to fewer maternal deaths, with Northern Ireland providing one example close to home: ‘Ireland and Northern Ireland show a low incidence of maternal and infant conditions known to be abortion sequelae: still birth…and maternal deaths. Liberalisation of abortion laws in Ireland and Northern Ireland can be expected to result in higher abortion rates and a corresponding deterioration in respect of these conditions affecting the health of women.’

Those who are ‘pro-abortion’ argue that where laws on abortion are more restrictive, more illegal (‘back street’) abortions take place leading to more complications and deaths. So, where abortion is safe, legal and accessible, maternal mortality drops: ‘Evidence demonstrates that liberalising abortion laws to allow services to be provided openly by skilled practitioners can reduce the rate of abortion-related morbidity and mortality.’

Into this debate comes some interesting research by Elard Koch, published in BMJOpen a few months ago, based on analysis carried out across 32 states in Mexico.

Koch does not take ‘sides’, instead making a simple, but important, claim based on his research in Mexico, that that differences in abortion legislation do not correlate ultimately with maternal mortality ie. abortion laws do not make the difference in women’s mortality rates (in Mexico).

This is useful. There has been a well funded (see here too) campaign for many years by pro-abortion groups pushing for all national abortion laws to be more permissive (using the euphemism ‘reproductive rights’), even within those countries culturally and legally opposed to abortion. It is argued that restrictive abortion laws are harmful to women. Maternal mortality rates and maternal health are both key to these claims.

This new analysis shows that such arguments are not tenable:

• Permissive abortion laws do not reduce maternal morbidity and mortality;
• Restrictive abortion laws do not harm women’s health and increase abortion-related mortality rates;
• States with restrictive laws do have lower maternal mortality rates, but this was not explained by abortion legislation itself.

Instead, not unsurprisingly, most of the differences (up to 88%) in maternal mortality between the Mexican states were largely explained by factors such as women’s literacy, maternal healthcare, emergency obstetric care, individual-level risk factors, clean water, sanitation, fertility rate and intimate-partner violence against women.

It is worth briefly explaining why this research in Mexico is particularly useful.

Each of the 32 Mexican states has its own political constitution, criminal code and abortion legislation. Some are more restrictive and some more permissive. Mexico therefore provides a unique epidemiological scenario to test the impact of abortion legislation on maternal mortality in a population that shares the same history and culture and (importantly) that has a homogeneous healthcare system. The authors were also able to use virtually complete official vital statistics of live births and maternal deaths in the 32 Mexican states between 2002 and 2011.

Koch and colleagues have since published in the BMJ (August 2015) an even more detailed analysis, in response to criticism of their research by a pro-abortion activist. They claim their research is: ‘Methodologically sound, with perhaps an uncomfortable result.’

They tackle directly the argument that: ‘Theoretically, in Mexican states exhibiting less permissive legislation, maternal mortality should have been higher because the practice of unsafe abortion should be more frequent.’

Instead, they found that: ‘Paradoxically, over a 10-year period, those states almost univocally exhibited lower figures for maternal mortality ratio (MMR), MMR with any abortive outcome and induced abortion mortality ratio.’

Nevertheless, despite this correlation, Koch et al do not attribute the cause to abortion legislation, but instead they say that the differences can be explained by other independent factors known to influence maternal health.

The main conclusion by Koch is that addressing disparities in these other factors – such as women’s literacy, maternal healthcare, water, sanitation, fertility rates and violence against women – will most likely facilitate a transition towards low maternal mortality rates in developing countries.

There is more to Koch’s work however.

In his rebuttal to criticism, he mentions a few other associations with reproductive health outcomes, which I found of interest (not related to Mexico or maternal mortality). For example:

1. Klick et al. assessed gonorrhoea incidence rates and found that, compared with very restrictive abortion laws, a switch to more permissive abortion laws is associated with large increases in gonorrhoea incidence. According to Klick, economic theory predicts that abortion laws affect sexual behaviour since they change the marginal cost of having high-risk sex (when barrier contraception is not used) leading to a higher risk for both STD acquisition and unintended pregnancy: ‘these results are consistent with a story whereby increased access to abortion leads people to engage in more risky sex.’
2. In a Spanish study over 10 years Duenas et al. reported an increase in the use of contraceptives (49% in 1997 to 80% in 2007), but at the same time an increase in the abortion rate (5.52 to 11.49 per 1,000 women), especially in young women, who reported engaging in high-risk sex more frequently. Interestingly, a Russian Longitudinal Monitoring Survey report begins by stating that: ‘Internationally, high abortion rates often are considered an indication that women’s access to effective contraceptives is inadequate’ yet these authors found that the availability of abortion was one of the reasons specifically cited for women not using contraceptives.

3. The prevalence of Down syndrome at birth is higher in settings with less permissive abortion laws: Chile (2.47 per 1,000), Argentina (2.01 per 1,000) and Ireland (2.1 per 1,000 in Dublin). The converse of this is that prenatal screening and more permissive laws of abortion have a strong impact on Down syndrome, decreasing the prevalence at birth to less than 1 per 1,000 in Europe.

But back to my title question, the answer to which is ‘yes’ and ‘no’. There appears to be a link, in that restrictive state laws have lower maternal mortality rates, but this is NOT explained by abortion legislation itself, according to this research.

If, therefore, the key determinants of maternal mortality are actually education, maternal health, sanitation and drinking water etc, then the implications for international policy are clear. But, as Peter Saunders has questioned here, will the lavishly funded birth control and abortion industry take note?

At last! The media has finally picked up on the ethical and exploitative mess that is egg ‘donation’.

I have blogged on this, included it in submissions, asked questions in conferences and, most recently, raised it when giving oral evidence to a Parliamentary Select Committee in April. The aim being to expose the industry around egg ‘donation’ and egg freezing that exploits women’s health and purses.

Now, thanks to the Daily Mail’s front page undercover investigation, the Humn Fertilisation and Embryology Authority (HFEA) has said they are investigating several fertility clinics accused of exploiting couples desperate to have children. Health Secretary, Jeremy Hunt says the allegations are serious and worrying.

 The major allegation against the fertility clinics visited by undercover journalists was that women were being convinced to donate their healthy eggs in return for free IVF, at clinics in London, Hertfordshire and County Durham.

But this is not just a story for journalists.

I personally know of a woman who was persuaded a few years ago to ‘donate’ half of her eggs for someone else’s fertility treatment, in order to have reduced cost IVF for herself and partner. Not only was she hospitalised by the procedure, years later, she is still highly traumatised having been unsuccessful in her own IVF treatment but knowing that her ‘donated’ eggs resulted in a successful birth for another woman.

Somewhere, she knows, she has a daughter, who she will never know.

This is real life. This is the dark side behind the industry. This woman has never had any longer-term practical or emotional help or support from the fertility clinic. She is on her own, literally (with no child), collateral damage from an industry that does not seem to care for the women it is exploiting.

Of course it could be argued that the other woman, who had a child from one of the donated eggs, has benefited. But has she? Has her husband/partner? What effect will it have on the child who will never know his/her biological mother?

Anecdotally, we know anonymous gamete donation can cause a lifetime of harm. The lessons to be learnt from adopted children are that they frequently feel a deep sense of loss if they don’t know about their genetic parents, despite having loving adoptive parents. Plus their medical histories are being denied them (indeed, the woman I know has a medical condition that has a genetic basis but has only recently been diagnosed, so it will never be known to the other family).

This website reveals some of the life long heartache of people who have been donor conceived.

To clarify, adoption is a biblical, positive and mutually beneficial act, providing a child for a childless couple and a loving home for a child in need. It is making the best of a difficult situation, whereas the fertility industry deliberately and intentionally creates difficult situations, and loss, for financial gain.

Unfortunately, I have to rely mainly on anecdotal evidence of harm because the HFEA, Government and regulatory bodies all fail to follow up women who have donated eggs, or women who have received donated eggs, or children who are born of donated gametes. It is an industry left to its own devices. We and others have called time and again for proper follow up.

But our concerns with egg donation go further than the Daily Mail investigation.

We urgently need more exposure of:

1. The unethical marketing of egg freezing to women. The success rate of egg freezing to live birth is just 0.95 per cent! And yet egg freezing costs £3,000 for three years.
2. The health risks of egg donation (here too). There is no follow up of women’s health after egg donation yet we know it can cause major, long-term, health issues, as well as psychological harm (as my story above illustrates).
3. The exploitation involved. Only disadvantaged, economically needy, infertile, vulnerable and – deliberately targeted – students donate eggs, rarely wealthy women. Why? Because it is risky, painful, invasive and emotionally damaging, so only those needing an incentive will consider doing it, ie for cash (£750 per cycle of donation) or free IVF.
4. The research industry. Women’s eggs are needed for embryo research (including for gene editing, creating three parent babies, hybrids etc), so how do scientists get hold of the hundreds of eggs needed for research? By enticing women with cash or cut price IVF. (See this advert here). Such incentives are essential because there are no health benefits for women donors – and it is ethically dubious research.

Does the health and well being of women count for nothing? Where are the feminists standing up for them? Where are the regulators? The lack of tracking, research and data is shocking. Egg donors need to know that long-term research simply is not there.

This is an industry built on the eggsploitation of women and it needs exposing.

For the past five years, the charity Marie Stopes International (MSI) has been given £163 million in UK taxpayer money to spend on abortions in developing countries. This money also went on helping to liberalise laws on abortion. No other country gives as much money to MSI than our own Department for International Development (DFID).

MSI is one of the main providers of abortion in England, but most of their business is to provide contraceptives and abortions in developing countries in order, they claim, to reduce the number of ‘unsafe abortions’ in developing countries and to reduce maternal mortality rates.  In 2016, they said they have ‘averted 7.6 million unintended pregnancies’.

Not only is this flawed reasoning for increased abortion provision, we have to ask if MSI can be trusted to carry out ‘safe abortions’ across the globe.

MSI abortions in the UK

It is hard to find out facts and figures. Data collection is very poor on abortion follow up in the UK. Even the RCOG acknowledges that there is ‘a lack of standardisation in reporting which hampers collection of accurate data.’ Private abortion providers do not record NHS numbers so health events cannot be linked to a prior abortion. In other words, many complications are missed off records and not collected by Government stats so we have no accurate figure of how many complications post abortion there are nationally.

Bearing that in mind, unannounced inspections of MSI clinics give us an indication of some of the outcomes of abortion. A highly critical Care Quality Commission (CQC) inspection report published in December 2016 found major safety flaws at MSI clinics, with more than 2,600 serious incidents reported in 2015. Now MSI has again hit the headlines here (and here) with news that they carried out nearly 400 botched abortions in just one month, earlier this year.

The latest report found:

• 373 abortion failures in one month
• 12 emergency transfers from MSI clinics to NHS hospitals in a two month period
• One recorded case where consent was given after the abortion had taken place
• Employment of an unregistered nurse
• Significant concerns with staff training, procedures, oversight of care, leadership and evaluation of equipment quality

One can only guess at what is happening in clinics where there have been no unannounced inspections.

This is happening in UK clinics, under relatively strict health and safety rules and regulations. Yet the irony of claiming to reduce unsafe abortions in developing countries while carrying out hundreds of unsafe abortions in the UK is probably lost on the provider of a significant proportion of MSI’s income, DfID.

DfID funding for abortions abroad

 In a Parliamentary answer Alistair Burt MP, Minister of State for International Development says: ‘By helping the world’s poorest women access modern contraception, we will prevent an estimated 6 million unintended pregnancies and 3 million abortions on average each year.’

 But even that is not enough.

Priti Patel, the Secretary of State for International Development, recently pledged an extra £225 million a year for family planning ‘aid’ for the next five years, including on ‘safe abortions’, up to a total of £1.1 billion. Much of this money goes directly to MSI.  How is it spent?

MSI abortions globally

Between 2011-2106 DfID gave nearly £100 million to one specific project called Prevention of Maternal Death from Unwanted Pregnancy (PMDUP), run by MSI and close partners. This money went to 14 counties across African and Asia with three of the four targets being to:

• Train over 12,000 health care workers in comprehensive abortion care
• Provide nearly 5,500 more service delivery sites
• Support locally led changes to the regulatory and/ or policy environments for abortion services at national level and across the Africa region
• A review of the project outcomes in 2015 reported that they had prevented 1.9 million ‘unintended pregnancies’ (read abortions) while in 2014 they prevented 1.4 million in these 14 countries.

Not only that, they also targeted and measured the number of ‘disability life years saved’ (their words, their metrics).  In 2015 this was 1.5 million and 2014 it was 1.2 million in 14 countries.

I find all these shocking statistics.

We talking about millions of lives lost and mothers harmed, using our money. I also find the language of ‘disability life years saved’ (a term I have not seen used elsewhere) incredibly offensive and the numbers very sad.

Then there are the MSI targets to liberalise abortion laws in Africa and Asia, again, funded by us. MSI ‘encourages’ countries to make policy changes (which of course gives them more ‘business’ and helps achieve higher target numbers of abortions).  As a consequence of this campaigning, eleven countries reduced restrictions on access to abortion or increased their own funding for abortions, and five regional declarations ‘adopted progressive language’ across the African region.

Here are a few quotes from one annual PMDUP report illustrating how UK taxpayer money is used to push deliberately for legal changes on abortion in Africa and Asia:

• MSI is ‘…proactive in all countries seeking Government money for reproductive health services.’
• ‘Advocacy for legal reform continued in Malawi…’
• ‘It is appropriate that PMDUP are proactive in all countries seeking options for government financing of reproductive health services.’
• MSI report success in ‘…directly influencing decisions by policy makers to allow expansion of services.’

Will this reduce illegal abortions and maternal mortality?

Again, facts and figures are hard to ascertain. Illegal abortions undoubtedly take place in developing countries but I suspect that the actual numbers are significantly below WHO estimates. A useful catalogue of known abortion statistics on line is that of William Johnston who challenges official figures here because of incomplete reporting.

As for maternal mortality, I explored this here in more detail. Research in Mexico where abortion legislation varies from State to State (and thus provides a unique scenario to test its effects) found that:

• Permissive state abortion laws do not reduce maternal mortality and morbidity
• States with restrictive abortion laws have lower maternal mortality and morbidity rates

While the research showed a clear correlation between restrictive laws and lower maternal mortality the authors did not claim this was necessarily a cause. Instead they said lower maternal mortality was best explained by literacy, maternal health care, obstetric care, sanitation and clean water.

However we cannot ignore the effect of abortion legislation, as the example of Chile shows. Strikingly, after abortion became illegal in 1989 in Chile, deaths related to abortion continued to decrease. A tighter law reduced deaths.

 The best way to transition towards low maternal mortality rates in developing countries is to address other factors – maternal healthcare, trained birth attendants, water, sanitation and women’s literacy etc. As Nigerian Obianuju Ekeocha says: ‘My lifeline out of poverty was education.’

It is not through a lucrative, unsafe, abortion trade, whose leading beneficiaries are paid more than government ministers from a shrinking health budget, operating under the protection of a bestowed charitable status, funded by us.

A year ago, I blogged about some of the global health challenges that Christians and Christian organisations would be facing in 2017. At the start of 2018 I thought it would be good to revisit some of those issues and look to others that are emerging in the coming year.

Changing Aid Climate

As predicted by almost everyone, the new Trump administration has proposed significant reductions in the US aid and development budget. This includes reducing funding for work on containing infectious disease outbreaks by the Center for Disease Control (CDC) in Atlanta; given the World Health Organisation’s poor track record on this issue, the withdraw of the CDC’s support could further weaken the global response to the next major infectious disease outbreak.

However, the issue that is at the top of most of the development community’s concerns it that the Trump administration has reinstated the so-called Mexico City Policy or Global Gag Rule. This means that USAID (US department for Aid and International Development) requires any aid agency that receives US funding to commit to not providing, counselling or informing women about abortion as a family planning option. This has already slashed funding from Marie Stopes International (MSI) and International Planned Parenthood Federation (IPPF) to the tune of $80 million and $100 million respectively. But the impact is wider, hitting national and non-US agencies, and some estimate that over twelve hundred NGOs will between them lose $2.2 billion in funding. While other governments and movements have increased funding to some of these agencies to the sum of around $450 million, the shortfall remains significant.

This will have two impacts. A lot of family planning services continue but are being provided by agencies that do not provide or counsel abortion. In other areas, services will be lost altogether or significantly reduced. While this is causing outrage in much of the development community, faith-based organisations are continuing to provide effective services, many funded by USAID, and many stepping into the breach left by MSI, IPPF and their like. The consensus that IPPF and MSI have created about family planning is being challenged. In fact, most countries, and indeed the UN itself do not include abortion in family planning definitions. Furthermore, the track record of bodies like IPPF and MSI is increasingly in question. While many in the development community are up in arms about the current US funding policy, the impact on maternal and child health may well be less disastrous than many claim.

Conflict

At the start of 2017, the war in Iraq and Syria was the big concern. Forcing millions to flee and become refugees in surrounding nations, Europe and beyond, while millions more left as internally displaced people (IDPs) within their war wracked countries. By the end of the year, while that war has begun to wind down, the biggest health crisis has shifted to Yemen where over a year of civil war supported by regional powers (and indirectly by many western and eastern governments including the UK) has led to the biggest outbreak of cholera on record, the re-emergence of long controlled infectious diseases such as diphtheria, and the near total infrastructural devastation that means the country could take a generation or more to recover, as and when the fighting ceases. At the time of writing, the prospects of this situation are so remote as to be laughable, but it is no laughing matter.

Meanwhile, civil wars and conflicts in Central African Republic and South Sudan leave many unable to grow food, get clean water or access health services, while also generating refugee situations of their own.

The persecution of the Rohingya in Myanmar has also created a major humanitarian crisis on the Bangladeshi/Myanmar borders that may rumble on for years.

War will continue to generate health problems for millions this year, both those directly affected and those in surrounding countries and regions to which refugees are fleeing.

Health Workforce

This is no new challenge, but it has once again come to the fore that there is a huge shortfall of health workers across the developing and developed world. In the UK we are seeing one in ten nursing vacancies unfilled and a shortage of General Practitioners and junior doctors. The US and other western nations are facing comparable shortages. This creates an opportunity for millions of doctors, nurses and other skilled health workers from developing nations to migrate, leaving their own nations even shorter of professionals than the West.

Another, largely ignored issue within this is that most of these health workers are women (at least 75%). While the #MeToo movement started in the West with celebrities, the realities not just of sexual harassment, but of discrimination and lack of access to education, good pay and chances for promotion that women face in many parts of the world mean the health workforce is still often ignored and under-resourced. As I have said elsewhere, just increasing our investment in training nurses has an impact not only on health, but also on development and the status of women in society. But the same challenges face midwifery, medicine and other health professions, and one of the issues at the heart of this is the status of women and whether female healthcare leaders will be listened to at national and global levels.

At present, the global health workforce is short of 18 million trained health workers. To achieve the SDGs by 2030 the WHO reckons the world needs another 40 million health professionals. Without adequate pay, training, working conditions and recognition, this simply won’t happen. And this is not just a developing world issue – as the current NHS winter crisis reminds us, the wealthy nations of the world are also falling short of health professionals at an alarming rate. The only difference is that we can afford to poach them from poorer countries, exacerbating the problem.

And the good news?

Has it all been bad in the past year? And is the future all grim? Leaving aside the natural pessimism of the British in January, especially when faced with the catalogue of disasters and challenges I have listed above, there turn out to be many encouragements and guarded reasons for optimism.

Firstly, some disasters never happened. A famine in South Sudan was averted, and overall the chances of people dying of famine has dropped globally to 0.06% of the figure in the 1960s. Famine early warning systems, better coordination of aid and emergency relief have all reduced the incidence of famine. Wars have killed fewer people in the last year. The war against ISIS has begun to wind down, and while the wider civil war in Syria may well wind back up with a focus on Syria, Iraq and now Turkey trying to supress various separatist groups on their borders (in particular the Iraqi and Syrian Kurds in the north of the region), overall the fighting has (for now) abated and reconstruction begun (at least in Iraq). This could all change at the drop of a bomb, of course, and the regional conflicts across the globe are almost all far from resolved. And the West’s tensions with North Korea threaten a conflict on a global scale!

We have plenty of reasons to give thanks, but also to pray for peace.

We also saw fewer deaths from natural disasters, such as floods, droughts, and (despite the awful hurricane seasons in the Gulf of Mexico last autumn) high winds.

Secondly, the global community is making progress on coordinated preventative health programmes. Vaccination rates are at their highest ever (86%) for the major infectious illnesses (diphtheria, pertussis, measles, Hepatitis B and rotavirus). New Zealand has completely eliminated measles in the last year, joining the UK, Australia and the Americas. Overall deaths from measles have now dropped from 550,000 in 2000 to 90,000 in 2016. It is significant progress, but there is still a way to go. Meanwhile, only 19 cases of wild poliomyelitis were recorded on Earth in 2017.

Life expectancy continues to rise in most countries (the UK being a notable exception over the last few years, where life expectancy is stagnating and even declining). Infant and maternal mortality rates are also coming down. Malaria vaccines will be rolled out to children in some of the most at-risk regions, and clinical trials of an HIV antibody that offers the potential of an effective preventative measure begin soon.

Finally, poverty is being reduced. Fewer people are living on less than $2 (£1.50) a day – about 200,000 people are being lifted out of extreme poverty every day. This is mostly due to a robust and currently booming global economy. The potential of poorer nations and communities to benefit from a strong global economy remains a challenge and an issue of social justice. One of the surest ways to improve health is improve personal and national wealth. Literacy has continued to increase, as has access to primary education (especially for girls) – both linked with increased health and wellbeing for communities.

Challenges for Christians

Persecution of Christians continues to be a major global issue – one that has been increasingly acknowledged by the West (albeit reluctantly).

We are also unpopular because we are challenging the consensus on issues like gender, sexuality, family planning, personal autonomy and freedom of conscience. The western aid and development movement do not particularly like working with us, and while bodies like the WHO and UN are recognising the need to work with faith communities, Christians who hold to their values and beliefs are more likely to be marginalised. Yet the narratives of the secular West are increasingly challenged and other voices are being heard.  I also suspect that the relevance of the WHO and UN in global health will change in the coming year.

In 2017 we remembered the 500^th anniversary of the start of the Reformation. Its impact on the world continues to this day, not least in medicine and healthcare. Christians of all theological persuasions continue to minister to the poor and sick in the most deprived areas of the world because of our faith in a Saviour who reached down into the mess and misery of rebellious humanity to reconcile us to God. Let’s continue to challenge the world’s values not so much by our words, but by our actions.

After successful lobbying by abortion providers, women in Scotland are now allowed to take the abortion pill at home, in a first for the UK. Since 83% of abortions in Scotland use medical methods (abortion pills) this will have a significant impact.

I’ve recently blogged on this change in Scotland, citing medical concerns with allowing women to take the abortion drug misoprostol in their own homes, as well as highlighting the ideology behind the change. However, as I’ve researched these blogs, I’ve realised that for abortion campaigners this is just a ‘step in the right direction’ towards all medical abortions in the UK being carried out on a fully at-home basis.

As I have spent time reviewing the physical and psychological costs, and dangers, of taking abortion pills at home, I have begun to realise how ironic it is that we are coming full circle and are returning once again to having abortions taking place in homes, or perhaps friend’s homes, or perhaps schools, or colleges, or in the house of an acquaintance or … why not in a park or other so-called ‘back street’?

Because once an abortion pill is no longer administered and taken in a clinic under medical supervision then, whatever campaigners claim, there is absolutely no control over where a pill is taken. Or when. Or by whom. Or if it is taken freely or under coercion.

Of course it will be countered that home medical abortions are much safer now than in the past.  But I’ve shown in previous posts (here and here) that complications from medical abortions are common, not rare, according to official criteria, and the regimen can take longer and be much bloodier and much more painful than advertised.  Indeed the Scottish guidance (but not the law) says a woman must have another adult with her and the pill must only be taken up to ten weeks gestation, thereby acknowledging it’s really not such a straightforward procedure.

In the UK we have poor data collection (so complications are often not linked to abortion) but in countries where data collection on abortions is better, we know that complications after medical abortion are four times higher than after surgical abortion – 20 percent compared to 5 percent. These complications include haemorrhaging in approximately one out of six women (15.6 percent) while more than three out of every 50 women (6.7 percent) had fetal tissue left inside, most of whom (5.9 percent) required surgery to get the tissue out. In one UK study over 50% of women needed subsequent surgical intervention!

Added to this is the increased potential for emotional trauma when one’s own home (or wherever) becomes the place of one’s abortion and women can see – and have to flush away – the baby.

We are not talking about small numbers of abortions here. In 2016 in Scotland there were 7,926 medical abortions while the number in England and Wales  was 107,873.  If we assume a complication rate of say 20 percent of 115,799 medical abortions, that is more than 23,000 women per year with complications, and this is with some medical supervision!

Any decriminalisation of abortion would clear the way for all medical abortions to take place outside of medical supervision, by removing the 1967 Act’s requirement that abortion take place in a hospital or other ‘place approved [for abortion]’.

Readers who still think my title ‘Back to the back streets’ is overblown hype should consider the longer-term direction of travel, as campaigners push for less regulation of abortion pills.

Given the growing availability of abortion-inducing drugs distributed through illegal websites that circumvent regulations, what will stop women obtaining abortion pills off the internet? Currently in the US there are already at least 86 websites from which the abortion pill regimen can be ordered online, without a medical prescription.

It will not be long before abortion starts on a smart phone. A girl can be in her bedroom at any time of the night, take a pregnancy test, realise she is pregnant, go on her smartphone and in 15 seconds be connected to an abortion provider who will ship her the abortion pills.  They’ll be aborting in their bedrooms and flushing their babies down the toilet. That is the reality of abortion in the not so distant future.  It will not be because these girls and women do not have access to medical facilities but because they don’t want others to know about the abortion and because they will be fed the line that it is safe, quick and easy.

But ordering powerful drugs off the internet poses real dangers. A recent paper published by Contraception sought to demonstrate the safety of purchasing abortion pills online, but their findings showed quite the opposite. For a start, all of the pills were successfully ordered without needing a prescription or any medical documents and none of the packages received had any instructions!  Packages were damaged in shipment, and incorrect dosages of the drugs were sent, mostly too low a dose (not that a woman or girl receiving the pill would know this).

Showing little concern for the health and safety of women, or for the importance of taking correct doses at the right times and gestation, the researchers concluded: ‘We encourage reproductive health providers, advocates and policy makers to think creatively about how the internet might be useful for enhancing access to safe and effective abortion.’

But with no prescription required by such websites, and no medical oversight at all, the safety nets in place to protect women are gone. Those who profit are the pill manufacturers and providers, as well as sex traffickers and disgruntled boyfriends. Already stories of such abuse have emerged from  London, New York, Kansas, Florida, Wisconsin and we can only expect to hear more cases.

Wikipedia defines an unsafe abortion as ‘the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both.’  And it states that ‘an illegal abortion may be called a back street abortion.’   In a further ironic twist, most people think that unsafe, illegal abortions only take place now in developing countries yet by this definition, self-administered home abortions, with no medical oversight, some using illegal drugs off the internet, takes us into a new era of unsafe, illegal ‘back street’ abortions in the ‘developed’ world.

The current campaign to remove the administration of the abortion pill, misoprostol, from medical supervision and oversight is part of a long-term goal for abortion activists. Their goal is to bypass medical professionals in the process of medical abortion and remove as many legal restrictions on abortion as possible.

This will be achieved step by step. Incremental extension is the name of the game.

A recent BMJ comment piece, celebrating the progress abortion providers believe that they have made towards full decriminalisation and easier access to abortion in the last few years, comments that: ‘A permissive legal framework is not sufficient to ensure access to abortion; skilled, willing providers are [also] essential…’ 

Interestingly, it seems that doctors may be increasingly reticent to be involved in carrying out abortions, thus leaving a potential gap in provision. So a goal for abortion activists is to increase the ‘abortion workforce’ by encouraging and training more doctors in abortion provision and by enabling nurses and midwives to become more involved in abortions, to fill the opening gap.

But that is not all. When more doctors refuse to be involved in aborting their unborn patients, what else is a pro-abortion industry to do?  One answer is direct to patient marketing:

1. Encourage more self-administration of medical abortions at home
2. Expand use of medical abortions at home, initially to the first trimester, (not just the first nine weeks), and then beyond
3. Encourage the two abortion pills (mifepristone and misoprostol) to be given simultaneously, not 24 hours apart.
4. Greater involvement of nurses and pharmacists in prescribing and providing pills (and doing abortions?), removing doctors from the process.
5. Encourage women to obtain pills off the internet and to bypass legal restrictions
6. Encourage women to lie if they cannot get hold of pills from a medical professional or pharmacist (more details below)
7. Carry out post abortion check-ups simply by using mobile phone apps
8. Get rid of as many legal restrictions as possible (see here too).

However:

1. Medical abortions are not as safe as usually implied, especially when self-administered (ie. do-it-yourself). There is limited data on the outcomes of self-administering abortion pills but one peer reviewed study found that 78% of participants had excessive bleeding, 13% had severe anaemia and 5% shock. 63% had incomplete abortion and 23% had failed abortion. They also found that surgical evacuation had to be performed in 68% of the patients, 13% with a blood transfusion. The authors’ conclusion? ‘Unsupervised medical abortion can lead to increased maternal morbidity and mortality.’ If they are so safe, why do medication guides for these pills warn they may cause a number of very serious side effects? And why are they only available in the USA through a restricted medical program (REMS) and only in certain healthcare settings? Furthermore, the medication guides note that there is no research on any possible link to cancer, while a package leaflet for the two pills admits there is only limited data on their use by adolescents.Even one of Ireland’s most vociferous campaigners for abortion, obstetrician Peter Bolyan, recently admitted that: ‘there are serious dangers when women take [abortion pills] without supervision. We have knowledge of women who have taken them in excessive dosage and that can result in catastrophe for a woman such as a rupture of the uterus with very significant haemorrhage…And if that happens in the privacy of a woman’s home or perhaps in an apartment somewhere, that can have very, very serious consequences for women. So, it’s really important that these tablets are…dealt with in a supervised way…’

2. The later in gestation that medical abortions take place, the less effective and the more dangerous they are. Ten weeks is the maximum gestation recommended. Because of increasing uterine sensitivity to misoprostol with advancing gestational age, regimens for medical termination change in the late first trimester and second trimester to repeated, lower doses of misoprostol. The woman’s experience will also be more painful later in gestation, with an exponentially increasing rate of haemorrhage and complications after just seven weeks gestation. Abortion advocates realise that ‘…Gestational age assessment before undergoing medical pregnancy termination is necessary to ensure women take the recommended dose and regimen of medications, and in the appropriate setting’ and yet even they report large variances in self-calculated gestational age. They found that one‐third of women who were followed up after receiving ‘treatment’ had pregnancies of ten weeks gestation or more, when checked by ultrasound. Some even had pregnancies of 18-28 weeks, far off the recommended maximum of ten weeks.
3. Taking both medicines at the same time causes more side effects and is less effective than when they are taken at least one day apart – the recommended protocol. One study (by authors who are pro-abortion) found that for women under 49 days’ gestation, the failure rate was 27% if they took the misoprostol immediately after mifepristone. For women between 50-56 days’ gestation, the failure rate was 31%.  The authors of this study strongly recommended that buccal misoprostol not be taken immediately after mifepristone because of the high abortion failure rate. Another study also concluded that a six hour gap ‘…is not as effective at achieving a complete abortion compared with the 36- to 48-hour protocol.’

4. As noted in a previous blog, self-administration of abortion pills removes any control over who takes the pills, where they are taken, whether they are taken, when in the process they are taken or if an adult is present. It also removes an opportunity to ascertain if abuse or coercion is involved. Little data is available however we know that coercion can take many forms and come from different sources. As well as direct pressure to abort (often from a parent or partner), it can include receiving false information from others, withholding of support from one’s family or emotional blackmail. Several news stories have described abortions forced on a woman by a partner who has given her a drug in food or drink without her knowledge.

5. Internet abortion providers deliberately encourage women to lie to get hold of abortion pills! One well-known provider states openly on its website: ‘To obtain one of these medicines, one could, for example, say that your grandmother has rheumatoid arthritis so severely she cannot go to the pharmacy herself, and that you do not have money to pay for a doctor to get the prescriptions for the tablets.’ And: ‘In many countries the pharmacy will ask for a prescription from a doctor, but sometimes you can get it without prescription if you are persistent and say it is for an ulcer (Cytotec), or for your grandmother’s arthritis…Don’t stop after the first “no”!’  Women on Waves also ‘helpfully’ shares that Mifeprex can also be bought on the black market from ‘places where you can also buy Marijuana‘.Women on Waves suggests: ‘If there are problems getting the medicines in one pharmacy, try another pharmacy, or a male friend or partner might have fewer problems obtaining them.’ While Women on Web say that while ‘Mifepristone is not registered in all countries … this should not be a problem because the medicines are for personal use only. Mifepristone can also be used as a morning-after pill, for the cure of depression, to treat breast cancer etc.’
6. Follow up using mobile phone apps is highly irresponsible, since complications from medical abortions are common, not rare. I cite above an example of the high rates of haemorrhage after medical abortion and the significant numbers of women requiring surgical follow up. Abortion pill provider, Women on Web, also found from their own surveys that 12–21% of women subsequently needed a surgical intervention and almost half of women who were over twelve weeks gestation (45%), required a surgical intervention. Information about abortion history becomes particularly and critically important when evaluating a woman for infection after abortion and yet, knowing this, Women on Web and Women help Women tell women that they can lie to their doctor, and claim they are ‘having a miscarriage’.

In order to increase access to abortions, it seems that abortion-rights advocates have gone from warning of back-street abortions to promoting do-it-yourself black-market ones. So much for the well-worn phrase, ‘Let’s make abortion safe, legal and rare’.

Not only does all this encourage illegal and dangerous practices (including the ability for abusers and pimps to get hold of pills, which can be discounted for packs of ten or more), with no medical professional involved there will be no objective gestational age dating, no guarantee that women read and follow the instructions, no objective screening for the medical and psychological contraindications (more common than for surgical abortion), no medical follow up with scans or visit, no access to emergency services.  And also….no potential malpractice issues to deal with.

On 25 July Louise Brown, the world’s first baby born via in-vitro fertilisation (IVF), celebrates her 40^th birthday.

40 years after her birth it is estimated that more than seven million babies have been born as a result of IVF and other assisted reproduction treatments. Around 2.4 million assisted reproductive technologies (ART) cycles are estimated to take place each year world-wide, with about 500,000 babies born as a result. If rates stay at current levels, then an estimated 157 million people alive at the end of the century will owe their lives to assisted reproductive technologies (1.4 per cent of the global population).

40 years ago it was generally assumed that IVF would remain rare. However there has since been an explosion of assisted fertility services:  intracytoplasmic sperm injection (ICSI), gamete and embryo freezing, gamete and embryo donation, embryo genetic diagnosis and surrogacy, to name some. The most common fertility treatment now is ICSI, accounting for around two-thirds of all treatments worldwide, with conventional IVF around one-third (proportions that vary across countries).

Infertility is deeply distressing and can affect every area of life for those struggling to conceive – as many as one in six couples. The Bible views childlessness as a painful, personal tragedy (Samuel’s mother Hannah’s anguished prayer illustrates the stress of infertility, as does Rachel in Genesis 30) while the Psalmist praises the God who ‘gives the barren woman a home, making her the joyous mother of children’ (Psalm 113:9).

IVF can provide couples with a child they desperately want. And it has brought many precious new lives into being, and real happiness to millions of parents.

Therefore, many now think IVF is the answer to infertility.

But it is not. While the IVF industry and media focus on and market the success stories, the average delivery rate from ART treatments are around just 19 per cent per cycle – a global IVF cycle failure rate of around 80%. In the UK, the Human Fertilisation and Embryology Authority reports a ‘success’ rate of 26.5% . This ‘success’ rate actually means that 73.5 % of cycles do not lead to a birth.

Success rates for IVF diminish rapidly after 35 years of age for women, largely because of loss of ovarian follicle reserve and oocyte quality with age. Even a woman under 35 years has less than a one in three chance of having a baby per embryo transferred, using her own eggs and partner’s sperm. A woman in her early 40s only has about a one in ten chance of having a baby per embryo transferred. And the success rate drops to a mere two per cent for women over 44. This is highly relevant in a time when more and more women are delaying childbirth to concentrate on jobs and careers. When celebrities in their 50s become pregnant, what the media do not tell you is that it is almost always with a donor egg (indeed, 59% of women over 44 years used donor eggs in their treatment).

IVF heartbreak is real. IVF is no guarantee of success, despite all too often being touted as such. Added to this is the significant financial, emotional and physical toll that IVF can have on women.

Yet still, with one in six couples experiencing problems conceiving, the fertility industry is thriving. It is estimated to be worth over £600 million in the UK alone, with one cycle of IVF costing up to £5,000 or more.

There are some very troubling aspects of the fertility industry.

For instance, the number of babies born with health challenges (see here and here too), the use of medically unproven techniques and ‘add-ons’, poor regulation, the shocking commercialisation and exploitation of women’s wombs and eggs (see here too) and the change to ‘traditional’ notions of family structure and biological parenthood, through gamete donation (which can bring much heartache to the offspring) and surrogacy. A dead or dying person can have their reproductive tissue removed to enable someone else to have a child – even a grandmother.

IVF has also opened what many regard as a Pandora ’s Box of genetic engineering, cloning, pre-implantation genetic diagnosis (screening out of embryos), embryonic stem cell harvesting, research on three parent babies and animal-human hybrids. Many IVF programmes involve the production of spare embryos, which are then used for research, disposed of, or frozen for future use. Between 1990 and 2013 over two million were allowed to perish, according to a Parliamentary answer. Now, over 170,000 IVF embryos perish every year. Embryos are experimented on, donated to other couples, frozen indefinitely … or even turned into jewellery.

The last 40 years of IVF and ART have given many couples happiness but even more couples, dashed hopes. The next 40 years will undoubtedly bring even more possibilities for the fertility industry, but what is possible is not always right.

What should we think as Christians?

Some biblical reflections on infertility treatments can be found in a CMF Nucleus article here and are summarised in a blogpost. Central to our response should be upholding the marriage bond and honouring embryonic human life. If these principles had been followed over the last 40 years many of the difficult issues that have come out of the fertility industry’s Pandora’s Box would not have happened.

I have also written a booklet with Dr Jason Roach which provides both information and guidance on some of the ethical dilemmas IVF raises for Christian couples considering IVF, and considers how we might seek treatments for infertility in line with God’s character and commands. We included two personal testimonies from Christian couples who both considered IVF and decided to take different courses of action.

A moral vision, especially one shaped by a Christian understanding of the person and family, has to be prepared to say ‘no’ to some exercises of human freedom and to turn away from technology that is possible but unwise. With fertility treatments, while we can and should use our God-given skills to help alleviate infertility we should also be prepared to acknowledge that there may be suffering we are free to end, but ought not to, that there are children who might be produced through artificial means, but maybe ought not to be.

Peter Saunders reflects in a blog here that some infertile Christian couples will go on to conceive, either naturally or with ethical infertility treatment, after a period of waiting. But this does not happen for all, and God in his wisdom has left some couples childless despite good treatment and patient prayer.

So this IVF anniversary could serve as our reminder to recognise God’s sovereignty, acknowledge we live in a fallen world, serve the childless with compassion, uphold marriage and honour all life.

Many abortion activists will have been delighted at the news that women will be able to self- administer abortion pills in their own homes. The head of the RCOG is on record claiming that having an abortion is no different to having a bunion removed.

Ironically, with this change that activists have been campaigning for, women will soon realise abortion is definitely not the same as removing a bunion – when they see the baby they have to flush down the toilet.

The boyfriend of one young girl describes what happened after his girlfriend took the second pill:

‘The day she took the final pill and came back to my flat to wait for it to pass truly drew a new line in the sand. The hours of pain she suffered, it utterly ripped me apart to see her writhing in agony, interspersed with trips to the toilet as the process started. It culminated in one trip from which she didn’t return, all I heard was sobs, drained of energy she couldn’t even cry with the force the pain deserved. I soon discovered that it wasn’t the pain the sobs were for, it was for what she had seen in the toilet. A recognisable shape. Then flushed away.’

But say we ignore any possible emotional damage to women (that not all will experience of course) and instead look at the claims being made that medical abortions are safe and self-administering the abortion pill is progress for women. What does the peer reviewed evidence show us?

To explain the process, in a medical abortion an oral dose of mifepristone is given at a clinic/hospital which will (usually) kill the fetus. Women leave the hospital or clinic then, with the current system, return up to 48 hours later to be administered misoprostol, either orally or vaginally. This expels the dead fetus. The change is that women will not have to return to the clinic but can take the second pill outside of any clinical setting or medical oversight.

It sounds simple and safe so what is my concern?

1. Medical abortions are not as safe s surgical

This is rarely acknowledged yet all the evidence is clear on this. The largest and most accurate study of medical abortions, a Finnish study of 42,600 women, found that women had four times as many serious complications after medical abortions than surgical abortions: 20% compared to 5.6%.

For medical abortions after 13 weeks, subsequent surgical evacuation rates vary widely between studies, but in one UK multicentre study reported by the RCOG (p42), it reached up to 53%.

 Research by pro-abortion authors found that for women over seven weeks the failure rate can be up to 33%.

2. Self-administering abortion pills is medically risky

Campaigner for abortion, obstetrician Peter Bolyan, has admitted that: ‘there are serious dangers when women take [abortion pills] without supervision. We have knowledge of women who have taken them in excessive dosage and that can result in catastrophe for a woman such as a rupture of the uterus with very significant haemorrhage…And if that happens in the privacy of a woman’s home or perhaps in an apartment somewhere, that can have very, very serious consequences for women. So, it’s really important that these tablets are…dealt with in a supervised way…’

One peer reviewed study of self-administering pills  found that 63% had incomplete abortion. Surgical evacuation had to be performed in 68% of the patients.

When self-administering pills, there is no control over: who takes the pills; where the pills are taken; whether the pills are taken;; when in the process the pills are taken; if the girl is vulnerable or in an abusive/coercive relationship; if abuse or coercion is involved in taking the pills or if another (competent) adult is present.

3. There is no demand for self-administration of medical abortion

Despite claims by abortion campaigners, there is no hard evidence or data showing that women are having problems with the current arrangements. Campaigners rely instead on (limited) anecdotal evidence.  The reality is that onset of bleeding is within four to six hours after taking the second of the two pills, giving sufficient time for most women to get home.  Surgical abortion is an option for those who cannot get home before bleeding begins, including those who cannot access medical services quickly after the abortion. Medical abortion is contraindicated for women with transport problems or issues.

So why the campaign to change the current situation?

This is just one step towards a longer term goal for abortion lobbyists, to make abortions as easy as possible, using nurses, pharmacists and internet suppliers, and to remove legal restrictions on abortion. Abortion providers have obvious financial and ideological vested interests in increasing numbers of abortions. And our Government knows that it is cheaper to pay for a couple of pills than a surgical abortion.

It seems that ‘progress’ today consists of moving abortions from unsupervised backstreets into unsupervised bathrooms.

The question of whether restrictive laws on abortion lead to fewer maternal deaths, or more maternal deaths, is hotly debated.

Those who are ‘pro-life’ and want to see more restrictive abortion laws say that fewer abortions leads to fewer maternal deaths, with Northern Ireland providing one example close to home: ‘Ireland and Northern Ireland show a low incidence of maternal and infant conditions known to be abortion sequelae: still birth…and maternal deaths. Liberalisation of abortion laws in Ireland and Northern Ireland can be expected to result in higher abortion rates and a corresponding deterioration in respect of these conditions affecting the health of women.’

Those who are ‘pro-abortion’ argue that where laws on abortion are more restrictive, more illegal (‘back street’) abortions take place leading to more complications and deaths. So, where abortion is safe, legal and accessible, maternal mortality drops: ‘Evidence demonstrates that liberalising abortion laws to allow services to be provided openly by skilled practitioners can reduce the rate of abortion-related morbidity and mortality.’

Into this debate comes some interesting research by Elard Koch, published in BMJOpen a few months ago, based on analysis carried out across 32 states in Mexico.

Koch does not take ‘sides’, instead making a simple, but important, claim based on his research in Mexico, that that differences in abortion legislation do not correlate ultimately with maternal mortality ie. abortion laws do not make the difference in women’s mortality rates (in Mexico).

This is useful. There has been a well funded (see here too) campaign for many years by pro-abortion groups pushing for all national abortion laws to be more permissive (using the euphemism ‘reproductive rights’), even within those countries culturally and legally opposed to abortion. It is argued that restrictive abortion laws are harmful to women. Maternal mortality rates and maternal health are both key to these claims.

This new analysis shows that such arguments are not tenable:

• Permissive abortion laws do not reduce maternal morbidity and mortality;
• Restrictive abortion laws do not harm women’s health and increase abortion-related mortality rates;
• States with restrictive laws do have lower maternal mortality rates, but this was not explained by abortion legislation itself.

Instead, not unsurprisingly, most of the differences (up to 88%) in maternal mortality between the Mexican states were largely explained by factors such as women’s literacy, maternal healthcare, emergency obstetric care, individual-level risk factors, clean water, sanitation, fertility rate and intimate-partner violence against women.

It is worth briefly explaining why this research in Mexico is particularly useful.

Each of the 32 Mexican states has its own political constitution, criminal code and abortion legislation. Some are more restrictive and some more permissive. Mexico therefore provides a unique epidemiological scenario to test the impact of abortion legislation on maternal mortality in a population that shares the same history and culture and (importantly) that has a homogeneous healthcare system. The authors were also able to use virtually complete official vital statistics of live births and maternal deaths in the 32 Mexican states between 2002 and 2011.

Koch and colleagues have since published in the BMJ (August 2015) an even more detailed analysis, in response to criticism of their research by a pro-abortion activist. They claim their research is: ‘Methodologically sound, with perhaps an uncomfortable result.’

They tackle directly the argument that: ‘Theoretically, in Mexican states exhibiting less permissive legislation, maternal mortality should have been higher because the practice of unsafe abortion should be more frequent.’

Instead, they found that: ‘Paradoxically, over a 10-year period, those states almost univocally exhibited lower figures for maternal mortality ratio (MMR), MMR with any abortive outcome and induced abortion mortality ratio.’

Nevertheless, despite this correlation, Koch et al do not attribute the cause to abortion legislation, but instead they say that the differences can be explained by other independent factors known to influence maternal health.

The main conclusion by Koch is that addressing disparities in these other factors – such as women’s literacy, maternal healthcare, water, sanitation, fertility rates and violence against women – will most likely facilitate a transition towards low maternal mortality rates in developing countries.

There is more to Koch’s work however.

In his rebuttal to criticism, he mentions a few other associations with reproductive health outcomes, which I found of interest (not related to Mexico or maternal mortality). For example:

1. Klick et al. assessed gonorrhoea incidence rates and found that, compared with very restrictive abortion laws, a switch to more permissive abortion laws is associated with large increases in gonorrhoea incidence. According to Klick, economic theory predicts that abortion laws affect sexual behaviour since they change the marginal cost of having high-risk sex (when barrier contraception is not used) leading to a higher risk for both STD acquisition and unintended pregnancy: ‘these results are consistent with a story whereby increased access to abortion leads people to engage in more risky sex.’
2. In a Spanish study over 10 years Duenas et al. reported an increase in the use of contraceptives (49% in 1997 to 80% in 2007), but at the same time an increase in the abortion rate (5.52 to 11.49 per 1,000 women), especially in young women, who reported engaging in high-risk sex more frequently. Interestingly, a Russian Longitudinal Monitoring Survey report begins by stating that: ‘Internationally, high abortion rates often are considered an indication that women’s access to effective contraceptives is inadequate’ yet these authors found that the availability of abortion was one of the reasons specifically cited for women not using contraceptives.

3. The prevalence of Down syndrome at birth is higher in settings with less permissive abortion laws: Chile (2.47 per 1,000), Argentina (2.01 per 1,000) and Ireland (2.1 per 1,000 in Dublin). The converse of this is that prenatal screening and more permissive laws of abortion have a strong impact on Down syndrome, decreasing the prevalence at birth to less than 1 per 1,000 in Europe.

But back to my title question, the answer to which is ‘yes’ and ‘no’. There appears to be a link, in that restrictive state laws have lower maternal mortality rates, but this is NOT explained by abortion legislation itself, according to this research.

If, therefore, the key determinants of maternal mortality are actually education, maternal health, sanitation and drinking water etc, then the implications for international policy are clear. But, as Peter Saunders has questioned here, will the lavishly funded birth control and abortion industry take note?

At last! The media has finally picked up on the ethical and exploitative mess that is egg ‘donation’.

I have blogged on this, included it in submissions, asked questions in conferences and, most recently, raised it when giving oral evidence to a Parliamentary Select Committee in April. The aim being to expose the industry around egg ‘donation’ and egg freezing that exploits women’s health and purses.

Now, thanks to the Daily Mail’s front page undercover investigation, the Humn Fertilisation and Embryology Authority (HFEA) has said they are investigating several fertility clinics accused of exploiting couples desperate to have children. Health Secretary, Jeremy Hunt says the allegations are serious and worrying.

 The major allegation against the fertility clinics visited by undercover journalists was that women were being convinced to donate their healthy eggs in return for free IVF, at clinics in London, Hertfordshire and County Durham.

But this is not just a story for journalists.

I personally know of a woman who was persuaded a few years ago to ‘donate’ half of her eggs for someone else’s fertility treatment, in order to have reduced cost IVF for herself and partner. Not only was she hospitalised by the procedure, years later, she is still highly traumatised having been unsuccessful in her own IVF treatment but knowing that her ‘donated’ eggs resulted in a successful birth for another woman.

Somewhere, she knows, she has a daughter, who she will never know.

This is real life. This is the dark side behind the industry. This woman has never had any longer-term practical or emotional help or support from the fertility clinic. She is on her own, literally (with no child), collateral damage from an industry that does not seem to care for the women it is exploiting.

Of course it could be argued that the other woman, who had a child from one of the donated eggs, has benefited. But has she? Has her husband/partner? What effect will it have on the child who will never know his/her biological mother?

Anecdotally, we know anonymous gamete donation can cause a lifetime of harm. The lessons to be learnt from adopted children are that they frequently feel a deep sense of loss if they don’t know about their genetic parents, despite having loving adoptive parents. Plus their medical histories are being denied them (indeed, the woman I know has a medical condition that has a genetic basis but has only recently been diagnosed, so it will never be known to the other family).

This website reveals some of the life long heartache of people who have been donor conceived.

To clarify, adoption is a biblical, positive and mutually beneficial act, providing a child for a childless couple and a loving home for a child in need. It is making the best of a difficult situation, whereas the fertility industry deliberately and intentionally creates difficult situations, and loss, for financial gain.

Unfortunately, I have to rely mainly on anecdotal evidence of harm because the HFEA, Government and regulatory bodies all fail to follow up women who have donated eggs, or women who have received donated eggs, or children who are born of donated gametes. It is an industry left to its own devices. We and others have called time and again for proper follow up.

But our concerns with egg donation go further than the Daily Mail investigation.

We urgently need more exposure of:

1. The unethical marketing of egg freezing to women. The success rate of egg freezing to live birth is just 0.95 per cent! And yet egg freezing costs £3,000 for three years.
2. The health risks of egg donation (here too). There is no follow up of women’s health after egg donation yet we know it can cause major, long-term, health issues, as well as psychological harm (as my story above illustrates).
3. The exploitation involved. Only disadvantaged, economically needy, infertile, vulnerable and – deliberately targeted – students donate eggs, rarely wealthy women. Why? Because it is risky, painful, invasive and emotionally damaging, so only those needing an incentive will consider doing it, ie for cash (£750 per cycle of donation) or free IVF.
4. The research industry. Women’s eggs are needed for embryo research (including for gene editing, creating three parent babies, hybrids etc), so how do scientists get hold of the hundreds of eggs needed for research? By enticing women with cash or cut price IVF. (See this advert here). Such incentives are essential because there are no health benefits for women donors – and it is ethically dubious research.

Does the health and well being of women count for nothing? Where are the feminists standing up for them? Where are the regulators? The lack of tracking, research and data is shocking. Egg donors need to know that long-term research simply is not there.

This is an industry built on the eggsploitation of women and it needs exposing.