Dr Kate Guthrie is a Fellow of the RCOG and has supported the RCOG’s Leading Safe Choices programme in South Africa and Tanzania.
Why is the availability of abortion care important for women?
For the health and wellbeing of their family and themselves, women of every age in every country need access to safe abortion for pregnancies they judge it is best not to continue. Only the individual can make the decision after weighing her personal pros and cons and it is her right to do so. Reasons are multiple, every women is unique, and choice must be respected. To do otherwise is medical and social arrogance.
What drew you to working in abortion care?
I witnessed the need. I was in the anti-abortion crowd as a student because it was a topic I had only been exposed to in theory as part of student debate. We were almost all middle or upper class in those days. It was even more stigmatised than today (this is back in the 70s). The moral reasons against were strongly represented and the needs of women never raised.
When I did my O&G jobs, I rapidly came across the harsh realities of women’s lives, particularly of women living in or near poverty or in circumstances of violence, whilst working within an insightful team which took the view that women should be listened to and their autonomy respected; the ethos from the top was in life ‘there but by the grace of god go I’, it was medical arrogance to presume as doctors we knew better than a woman herself what her needs were, and no woman should be punished for an unwanted pregnancy by being made to have a child. Abortion for fetal anomaly or maternal ill health was not an issue. From the woman’s perspective, how she was treated was a lottery, depending on the consultant whose care she was under. All junior doctors had to partake in the clinics and surgical procedure (it was pre-MTOP) and that was also wrong; some really suffered as it was against deeply held religious beliefs. We used to trade sessions to let them avoid the lists.
I witnessed games being played to delay procedures/ have to see a social worker for social reasons/ punish women psychologically/ make them beg and be humiliated. It encouraged lack of honesty in the consultation with women saying what they thought would gain their abortion, not what was really going on in their lives so helping them holistically was difficult. I saw the poor relationships between mothers and children they never wanted. It was so wrong I determined to continue with abortion care wherever I could as a trainee and took up contraceptive care because women had abortions then were sent off with no immediate protection against further unplanned pregnancy. As a consultant, I offered to run the local abortion service to stop the local post code lottery (it was rife everywhere I worked) to the delight of colleagues (and despised by others) and did so the rest of my career. My regret was never being able to make management, medical/ nursing/ administrative, provide later gestation procedures locally.
Internationally; I have never provided but would support where I can because women are the same the world over, the risk of injury and death being infinitely higher than other countries than in the UK.
Since you became an O&G how has the landscape around abortion changed?
It used to be what every O&G trainee and consultant was expected to do which was wrong for the reason given above, but there was local provision. Now, conscientious objection is used as a cop out to avoid training and provision so time can be spent on what the doctor wants to do, not provide what women need.
The up side is the postcode lottery should have gone if commissioning is carried out correctly. Grounds C&D are respected by doctors signing HSA1s (i.e. supporting the abortion request); women have more autonomy. The majority of abortion care is provided in the independent sector by staff who want to work in the sector which should minimise poor attitude. But students and trainees, nurses, ancillary staff and management are not exposed like I was, so why would they recognise the need?
There is a workforce crisis for late and complex cases due to the above. Contraception has gone from O&G across the breadth, it is minimal in the curriculum and it seems missing from Obstetrics. So no wonder there are mistimed and unwanted pregnancies when women have to navigate a fractured health care system.
The law and regulation is no longer fit for purpose with the introduction of medication abortion. It also inhibits some doctors taking part in the service.
Commissioning and service design needs to take account of the additional challenges some women have which affect abortion access like stigma, poverty, family and childcare commitment, travel, personal poor physical and mental health and partner and family coercion and abuse.
National surveys show the population is more pro-woman’s choice although it varies between countries.
As an abortion care provider/advocate have you experienced stigma within the healthcare system? If so, what steps do you think would address this?
Yes. Steps to change; attitude change to abortion in the population and specifically in the profession. Hearing the woman’s side of the story is possibly the key to this.
What do you think are the key priorities to ensure abortion services are sustainable today and into the future?
Collegiate leadership to embed abortion care as a professional responsibility, to support include training and providing within the clinical unit if not delivered by every gynaecologist. True conscientious objection must be respected. This to address stigma, workforce and the provision of local services flexible to women’s needs, either in NHS sites, independent sector sites or collaboratively.
Legal and regulation review to reduce barriers and hurdles. Women are accessing medical abortion online. This is not as safe as clinically supervised provision, especially when women are desperate and the subject is so stigmatised. This will also reduce cost.
What impact do you think the decriminalisation of abortion would have on abortion care services?
This would depend on what replaces it. There is the potential for more accessible, less time consuming and cheaper services for both women and providers, certainly for earlier gestation, with care being driven by best practice alone. Increased nurse involvement in surgical services would increase workforce.
Guaranteed contraception of choice provision. Appropriate multidisciplinary involvement. A true health and social care integrated approach. Potentially less fear in Doctors which I think is due to either lack of understanding of current law and regulation or fear that their interpretation of same will not be the regulators interpretation as happened with HSA1 pre-signing.
What role is there for post abortion family planning in abortion care services?
It should be deeply embedded in abortion provision with no service cop outs. Am I misunderstanding the question? It’s a no-brainer.
This interview has been condensed and edited.