Abortion Numbers in Ireland

You may well have read recently that each day nine women travel from Ireland to clinics in England and Wales to access abortion services; whilst this number is correct, it does not fully account for the total number of abortions in Ireland.

Each day, nine women officially register as travelling from Ireland to England or Wales for an abortion, we don’t know how many women self-administer medical abortion or use unsafe methods, but this is probably at least another three each day. Women on Web suggest this may be as high as five, so a total of 14 each day.

In 2016 a total of 3,265 women (nine per day) who had an abortion in England or Wales registered as resident in Ireland, very close to the 1980 total of 3,320. The number has been higher in intervening years and reached a high of 6,673 in 2001, an average of 18 per day.

Irish Visits to E&W Clinics annually

Does this mean that the total annual number of abortions in Ireland has reduced over the last 15 years? I don’t think so. I’m not aware of any interventions or related changes which might have caused a 50% drop. I suspect that the total number today is much the same as it was in 2001.

So what has changed? Perhaps:

  • An increasing number of women in Ireland are accessing abortion medication online or from contacts abroad and self-administering at home, and thus not appearing in any official registration data;
  • Some may travel to England or Wales but do not register as being resident in Ireland;
  • Some may still be inducing their abortion using unsafe methods, and I hope that this number is very small and will become a historical factor after the referendum this month.

Assuming that the referendum vote on May 25 is in favour of a change, it will be very interesting to see how the Irish government shape and implement the delivery of abortion services. I hope that those given this responsibility will be willing to take advantage of recent clinical research and pilots of new service delivery models. I hope that they don’t take the easy approach of replicating existing service models in eg England.

 

 

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How Many Abortions in Ireland?

I think that recent estimates showing 4,400 Irish women having an abortion in 2016 is too low, the number is likely to be much higher than this.

The Irish Times recently ran a fact check piece confirming that Solidarity’s claim that more than 170,000 Irish women have travelled abroad for an abortion since 1980 is correct. This is derived from data released by the Department of Health in the UK and similar data from the Netherlands. These data show that in 2016, 3,265 women gave Irish addresses when registering at an abortion clinic in GB.

I think this is a conservative estimate and that it is quite likely that
many more Irish women have had an abortion.

“So what?” I hear some say, but it is important that we establish reliable data which can be used to inform the planning of services delivery and SRHR strategies such as ensuring easy and affordable access to the most effective forms of contraception, for all women who want this.

On May 25th, residents of Ireland will have the opportunity to vote in a referendum to decide if the 8th amendment should be abolished or continue. The amendment essentially restricts access to safe abortion in Ireland. Lack of reliable data is just one consequence of these legal restrictions, and in noting this I am in no way minimising the significant personal impact on the Irish women who are seeking an abortion.

At a Together4Yes campaign meeting on Irish 21st Leo Varadkar, the Irish Taoiseach sat in front of a banner showing the following data:

  • 9 (on average) Irish women travel abroad every day for a termination of pregnancy;
  • 3 Irish women every day take abortion pills obtained online;
  • In 2016 3,265 women travelled abroad for abortions. They came from every county in Ireland.

Together4Yes 2

Whilst this is using the same number for those Irish women who travelled abroad for an abortion in 2016, 3,265, it adds a new dimension, estimating the number of those who self-administer medical abortion at home.

Added together, plus the 34 registering at Dutch clinics, we find an estimated total of just over 4,400 Irish women having an abortion in 2016.

I think that even this larger estimate is still too low.

In Ireland, there are 997,000 women of reproductive age, WRA, 15-45, based on 2016 census data. Using the above estimate of 4,400, we find an abortion rate equivalent to 4.4 abortions per 1,000 WRA per annum. We should note that if this estimate is correct, then Ireland has an abortion rate lower than all of the other country estimates made by Guttmacher. Switzerland at 5 per 1,000 is the lowest rate which I have seen reported, and so this Irish estimate might be correct, women in Ireland might be accessing abortion at the same rate as those in Switzerland.

However, I think it is more likely that women in Ireland are more similar to those in GB where the abortion rate is 16 per year per 1,000 WRA so there may be as many as 16,000 abortions in Ireland each year.

This is a very wide range, from 4,400 to 16,000, and whilst we might assume for planning purposes that the rate in Ireland is lower than in England and Wales, it has to be higher than the rate reported by the Taoiseach and by Solidarity.

I would speculate:

  • that some women who travel from Ireland to England and Wales for an abortion do not provide correct information about their location of residence, and so are not counted as Irish;
  • or that many more Irish women are travelling to other countries and do not appear in official data;
  • or that many women are self-administering medical abortion or accessing other alternatives in-country and these cases are not being reported.
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Financial Breakeven for Small Maternity Centres

The following is a very simple model for financial sustainability in small maternity centres. This is derived from a number of complex and detailed models used across a range of different country settings.

Ensuring that we meet safety and quality standards, and client affordability, I have not been able to find a breakeven at less than 80 deliveries per facility per month.

This is essentially a people business, the payroll can be as much as 65% of total expenditure.

Breakeven BalanceFacilities providing CEmONC services need to operate on a 24/365 basis. On each shift, we need minimum staffing of one medical officer, one midwife and one clinic aide. This assumes that anaesthesia when needed, will be provided on a sessional basis by calling one of a number of appropriate specialists from an on-call pool.

Across each week there are 21 eight-hour shifts, and the normal working pattern will be five shifts per week. Therefore we need at least 4.2 FTEs for each staff role, ideally, 5 to cover for holidays, offs and training days etc.. Yes, there are other shift patterns which can be deployed but the number of FTEs required will be much the same.

Let’s push the limits a bit and staff at just four FTEs per role. When modelled for an example country:

  • Monthly payroll for four each of MOs, Midwives and Clinic Aides = ~£10,500.
  • Thus the total monthly expenditure = ~£16,000.
  • Let’s call this £17,500 which provides some contingency and perhaps a small surplus.
  • Typical service prices for the same country are £125 for a normal vaginal birth and £375 for a C-section.

Whilst noting that income can be earned from the provision of other services, let’s just model the minimum number of deliveries required in order to fully recover the above monthly expenditure.

We only want to provide C-sections when indicated and so a maximum service mix would be 80% NVD and 20% C-section. From this, we derive an average income per delivery of £175, and thus we need to provide at least 100 deliveries each month in order to break even.

I have repeated this modelling many times, in much greater detail, and across multiple country settings, and have never been able to find a breakeven at less than 80 deliveries per facility per month, without exceeding guidelines for the C-section ratio, or without reducing staff numbers below safe and efficient levels, or without being paid higher rates which are often unaffordable for the majority client paying out-of-pocket.

 

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Is Abortion Choice Different In NE England?

A fundamental tenet of abortion care is the choice of the woman. This choice is not just about whether to have an abortion or not, but also about the choice of method by which the abortion is performed.

Data provided by the Department of Health for England and Wales show that being able to access the abortion method of your choice might depend on where you live.

Women being served by the Clinical Commissioning Groups in eg NHS Hartlepool and Stockton-on-Tees, and NHS South Tees, are very much less likely to receive their abortion method of choice – why?

In 2016, 190,406 abortions were provided across England and Wales, 4,810 of which were provided to non-residents.

There is a trend towards a choice for medical abortion (taking tablets – mifepristone and misoprostol) – in 2016 62% of abortions were medical, the remaining 38% by a surgical method.

Medical abortion is usually only provided up to 10 weeks gestation and in 2016, 81% of abortions in England and Wales were performed at under 10 weeks. This means that some women who present for an abortion at under 10 weeks choose a surgical method.

Across England and Wales, 98% of abortions are funded by the NHS; 30% are provided in NHS facilities and 68% by the Independent Sector, eg MSI and BPAS.

We expect abortion data trends and averages to be broadly the same across the country, and so when we note large variances we should ask why? Variation from one Local Authority to another could of course be for a large number of reasons, including some random factors, but these differences might also be influenced by local policy decisions.

Surgical vs Sector

The above graph shows that in places in which the lowest proportion of abortions are being provided by the Independent Sector, there seems to be a correlation in a lower proportion of abortions being provided by a surgical method.

NHS Hartlepool and Stockton-on-Tees, and NHS South Tees are particular outliers:

  • Less than 3% of abortions are provided by the Independent Sector, compared to an average of 70% across England;
  • Only 2% of abortions are provided by a surgical method, compared to an average of 38% across England;
  • 78% – 80% of abortions in these two locations were performed at under 10 weeks gestation, the same as the avg across England.

Note: data for 2015 show similar results, so this is not because of the withdrawal of services by MSI in some places during Q3/4 of 2016.

Why is abortion different in these locations

Would we be correct in thinking that it’s probably not a difference in the local women’s choice, and more likely to be caused by policy and system bias?

 

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C-section Births hit 50% in Kenya

The Daily Nation in Kenya recently raised concerns about the increasing numbers of births which are being delivered by c-section, now estimated to be 50%. This is very much higher than the rate thought ideal by the WHO, 10% – 15%. Apart from the high rate, the piece also discusses the financial pressure which this places on the national insurance fund, NHIF.

Whilst noting, and agreeing, that a delivery should only be by c-section when it is medically indicated, I am not at all surprised that this rate is so high – especially when insurance-funded.

Maternity hospitals can either be midwife-led, providing BEmONC services or doctor-led providing CEmONC services, which of course include c-sections. The latter approach has a much higher fixed-cost base, a doctor costs more than a nurse/midwife and there are additional staff and equipment costs for the operating theatre, eg in the provision of anaesthesia.

In Kenya, a doctor’s salary can be approx KES 250,000 per month, and participating facilities are reimbursed 30,000 by NHIF for each c-section provided. A maternity facility only needs a doctor on staff if it is providing c-sections, normal vaginal births can be managed by a midwife. It needs at least eight c-section reimbursements to cover this additional payroll cost, never mind all of the other additional costs. A facility which has just one doctor, and wants to maintain an indicated c-section rate within the ideal range, 10%-15%, needs to be providing ~55 deliveries each month, to justify taking on the extra cost of this one doctor, and more than this to fully recover the other costs of the operating theatre. Note that an OB/GYN consultant costs twice as much as a medical officer (doctor), and so the resulting pressure to increase the c-section rate for revenue purposes is even greater.

Here are 3 interventions which could reduce the moral hazard of increasing the rate of non-indicated c-sections under NHIF in Kenya:

  1. Lobby the Government of Kenya to increase the NHIF reimbursement rate for each c-section, this should take full account of the added operating theatre payroll and equipment costs;
  2. Change the client segment mix to favour those paying out-of-pocket, and set c-section prices at full cost-recovery, which will most likely be higher than the current NHIF reimbursement rate;
  3. Diversify services for which we can deploy the doctor and theatre staff to defray these high fixed costs, eg provide gynae services and minor surgery.

 

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Abortion Rates Vary Significantly

The abortion rate in Uganda, 39, is three times greater than in GB, 13.
The abortion rate in Kampala, 77, is twice the national average.

There is one complication for every 2.4 abortions in Uganda, a rate which is 262 times higher than in England and Wales.

If you work in sexual and reproductive health and rights, SRHR, and/or have an interest in maternal health, then you probably review the abortion rate data for your country of interest. Last month Guttmacher published a new report which highlights the ongoing disparities in abortion rates and in access to safe abortion services across the globe.

A key headline from Guttmacher outlined how abortion rates have remained steady across developing regions while declining in developed regions. In the latter, the average abortion rate, the annual number of abortions per 1,000 women aged 15-45, dropped from 46 in the years 1990-94, to 27 in the years 2010-14; in developing regions the movement was from 39 to 36. These are averages, and most are estimates rather than based on actual clients’ data.

In England, the doctor responsible for the abortion client must notify the Chief Medical Officer by completion and submission of the Abortion notification form, HSA4. The average abortion rate is derived from data on these forms, and so it is reliable for planning purposes.

In many countries, such as Uganda, the abortion rate is estimated using the Abortion Incidence Complications Method (AICM), which is explained in a research paper by Prada E et al “Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003” published here on PLOS One. Researchers also examine patterns of hospitalisation due to abortion-related complications, a key indicator of morbidity resulting from unsafe abortion.

Going beyond the headlines and global averages we see that the abortion rate estimated by Guttmacher for Uganda is 39, three times greater than the rate in GB, 13 (this is noted as 16 for England and Wales in the latest Department of Health Report on abortion statistics in England and Wales for 2016). There are many reasons for this significant difference, and in a recent post I noted five actions that are necessary to address the disparities:

  • Allow women and adolescents self-determination;
  • Make effective contraception easily accessible;
  • Change restrictive legislation;
  • Remove price barriers;
  • Train and equip willing Health Service Providers.

During 2016 in England and Wales there were a total of 190,406 abortions, and only 294 reported complications, which is a very low rate of about one complication in every 630 abortions. The latest annual data for Uganda, 2013, show a total of 314,304 abortions, from which an estimated 128,682 women were treated for complications. This is a staggeringly high rate of one complication in every 2.4 abortions, 262 times higher than in England and Wales, which demonstrates the very significant detrimental impact of unsafe abortions on women’s’ health.

Going even further into these Uganda data we find that the estimated abortion rates vary widely across the country, and eg in Kampala the rate is twice the national average. It is also worth noting the variance between the low and high AICM estimates, the bars shown in this graph.

Uganda Abortion Rate

We need to be aware of these regional differences when planning and, of course, also take account of the total estimated numbers in each, as shown here for 2013.

Uganda Abortion Numbers

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Medication Abortion – Guttmacher Report

Here are three issues which I think could come from an increasing move towards self-administered medication abortion, across developing and restrictive regions:

  1.  The business model for clinic-based abortion services will need to change;
  2.  There will be a reduction in the number of clinics in which staff are trained and willing to provide surgical abortion; and
  3.  The rate of effective post-abortion contraception will most likely drop.

The recent Guttmacher report, Abortion Worldwide 2017, provides some very interesting insights into the impact of medication abortion (abortion induced using either mifepristone and misoprostol combined or the latter alone).

In highly restrictive contexts clandestine abortions are now safer because of the availability of misoprostol, and to a lesser extent mifepristone, because women are choosing a medication approach rather than dangerous and invasive methods. From a public health and harm reduction perspective, this is great news.

In countries in which the abortion law is much more permissive, the choice of method is moving from surgical (either manual vacuum aspiration, MVA, or dilation and evacuation, D&E) towards medication. In some countries this trend is remarkable, eg Finland, Mexico and Sweden, in which an 80:20 balance of surgical:medication has now swung the other way to 20:80.

In England and Wales, medication abortions accounted for 62% of the total in 2016. This is higher than in 2015 (55%) and more than double the proportion in 2006 (30%). In some places in Britain, the choice of method is very heavily skewed towards medication abortion, which may be an indicator of other factors, so rather than being solely due to a woman’s choice might this indicate the lack of available surgical method, eg Hartlepool and Stockton-on-Tees 98% medication; Merthyr Tydfil 96%?

A key point to note is that all of these abortions are clinic-based, regardless of the method chosen.

There is a real concern that as more women choose medication abortion over surgical, that the number of clinics in which trained staff are available and willing to provide surgical abortion may decline to the point of not being sustainable or not being easily accessible. Here’s a news piece about such an issue in Tasmania.

The trend towards medication abortion is building across most developing countries and whilst this is very positive in terms of harm reduction, there are important differences when compared to developed countries. In the latter, the availability and provision of abortion medication are strictly controlled and only accessible in registered clinics, the medication cannot be purchased in a pharmacy.

Across developing regions, and particularly in those countries with restrictive legislation, we often find misoprostol easily available in low-level pharmacies, sometimes referred to as drug shops. One might consider this to be an important step forward in harm reduction, and as noted above the numbers of serious incidents from less safe methods does decline when misoprostol is available in this way. However, this is not the same as we see in clinic-based services in England and Wales.

The problem is not so much that the medication being sold is not of good quality, very often these are the brands which we ourselves are promoting and using in our clinics. The problem is in how these are sold. Women don’t always receive clear, comprehensive guidance on how to self-administer, and sometimes the dosage sold is simply not correct, less than required.

Even when a woman is able to buy the correct dosage of high-quality medication, and she self-administers correctly, abortion using misoprostol only is just 75-90% effective. When the abortion remains incomplete, or other problems arise, the woman will need to seek clinic-based care.

In retrictive contexts women wanting to access and self-administer medication abortion must:

  • Be given the correct dosage of high-quality medication;
  • Receive clear, comprehensive guidance on how to self-administer;
  • Be aware of what to expect normally;
  • Be aware of possible side-effects; and
  • Know from the outset how to get help if needed.

Let’s extrapolate this, eg in Uganda if all of the 800 abortions each day became self-administered and the misoprostol-induced abortions were 90% effective, that would mean about 80 women would need clinic-based post-abortion care each day. That’s a significant and welcome drop from the current 240 women being treated each day for complications arising from unsafe abortion, but only if the five points above are fully realised.

As more women choose self-induction of medication abortion, very many of them will miss out on the opportunity to receive, in a timely manner, an effective means of post-abortion contraception.

This growing change in abortion market dynamics, the move away from clinic-based services to self-administered out-of-centre, is a critical factor which healthcare planners need to take into account.

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Abortion Worldwide 2017: Uneven Progress and Unequal Access

This week Guttmacher published its latest data and analysis on the worldwide incidence of abortion and unintended pregnancy. For many countries, it has trends going back to 1990. A key message is that the rate of abortion has been falling in developed countries such as the UK, but has essentially flat-lined across developing regions.

Each year there are ~55 million abortions worldwide. The rate across developing regions, as shown here, is 36 abortions each year per 1,000 women aged 15–44. To get a better understanding of this, the rate suggests that on average each woman in these countries will have one abortion during her lifetime. In both the USA and GB the rate is 13 per year per 1,000 women of reproductive age, suggesting that one woman in three will have an abortion in her lifetime.

How each of these women accesses and experiences her abortion varies significantly, not just from one country to another, but often even within a country. This variance applies not just to developing regions, but can also be seen in the USA and the UK. For women living in NI, their experience is very different from those living in mainland GB. In the United States, it depends on which State you live in.

Of all abortions, an estimated 55% are safe, those performed using a recommended method and by an appropriately trained provider; 31% are less safe, meet either method or provider criterion; and 14% are least safe, meet neither criterion.

A key factor determining whether women have access to a safe abortion is the legal status of abortion in that country – where laws are more restrictive the proportion of less and least safe increases.

We all want to see a reduction in the rate of abortion, and an end to all unsafe procedures.

In order to drive a reduction in the rate of abortion, and a cessation of all unsafe procedures across developing regions here are five things that we need to do:

  • Allow women and adolescents self-determination;
  • Make effective contraception easily accessible;
  • Change restrictive legislation;
  • Remove price barriers;
  • Train and equip willing Health Service Providers.
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Be Careful Which Data You Compare.

fr333Last week the Uganda Bureau of Statistics released the 2016 Uganda Demographic and Health Survey (2016 UDHS). My initial interest in this was to find out how the country has progressed in its aim to reduce maternal mortality, and how likely it is to meet the Strategic Development Goal, SDG, 3.1. This is a global target of reducing the maternal mortality ratio, MMR, to less than 70 per 100,000 live births by 2030, with no country having an MMR greater than 140. Clearly an ambitious target, and for many countries, this will be a significant challenge.

On the first read and, I have to admit, after allowing myself to be misled by one of the Ugandan press, I thought good progress was being made and tweeted so:

#Uganda has made great strides in #maternal health. MMR reduced from 438 deaths per 100,000 live births in 2011 to the current 336 deaths per 100,000 live births. Well done @MinofHealthUG let’s keep this trend going and meet #SDG 3.1. #UDHS2016

but, I was wrong.

@DHSprogram quickly commented back to correct me, in their words:

The definition of MMR changed between the 2011 & 2016 UDHS, so you can’t compare. Previous UDHS surveys show pregnancy-related mortality ratio. The PRMR trend indicates a decline, but the sample size of surveys was not large enough to detect a significant change.

Trends in PRMR

This declining trend is simply not fast enough to reach the SDG 3.1 target. In the fifteen years to 2016, the decline has been ~30%, which if continued until 2030 would mean that the PRMR would still be in the mid-200s.

All of us who are working to deliver maternal healthcare in Uganda will need to do much, much more. We need to determine what is working, which are the initiatives helping to reduce MMR, and how can we do more with these?

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Three Days in Badistan

Earlier this week I was with a team tasked by the UNDP with fact-finding in an IDP camp. To be honest, it was chaos. I led the team in, and after some confrontation with the camp leader we had to leave again. After regrouping and better observation of protocols, we were asked to come in and meet with the camp inhabitants. A short time later, just when we thought we were making some progress, it all kicked off. Armed men entered the camp and went straight for the camp leader. They were not happy that he was colluding with the enemy, us. I overheard them saying that they were being paid to protect the camp, that the UN was the enemy and not to be trusted.

The one in charge looked at those around him, pointing his gun at each one of us with menace, and then he singled out a young lad from the camp. Calmly and quietly, all the more frightening, he ordered his comrade to shoot him. A deafening bang and the kid was dead. I kept my head down, trying to blend into the shadows and started looking for an escape.

The killer then took hold of one of our team, a young woman, and was about to take her from us – one of the possible scenarios that we had discussed when doing our risk assessment. Back then we had debated whether we would fight back or stay quiet, and one of our colleagues had stated quite simply and clearly that she didn’t want to be taken off and raped. The expectation of support hung heavy in the air, but I continued to keep my head down, trying to blend into the shadows and looking for an escape… this was not going to end well.

Then the bastard in charge grabbed the camp leader and ordered him and a female doctor out of the camp. As we watched them disappear through the gates two shots rang out, followed by haunting screams. Then silence.

After some time we started to stir, and a few of us headed for the gates. There we found the two alive, but badly wounded. I went to help the doctor, brought her back over to one of the benches, and using my newly acquired first aid knowledge, I attended to the horrible gunshot wound on her left hand.

Now I was staring to feel good, feeling useful again. At last I was meeting a need and making some difference. Short-lived.

She looked deep into my eyes and asked me why I had come, why we had brought all this trouble on them. I said that we were here to help, but she said look at what has happened because you are here. We need food, water, medical supplies, and you brought none of these. You brought only your stupid questions. Why did you come, aren’t there those in need back at home that you should be helping instead of coming here, to something you don’t understand, don’t know anything about and cannot help with? I felt hollowed out, unable to look her in the eyes, conflicted, and confused.

A baptism of fire in Badistan – a role-play training camp in the woods a few miles SE of Gatwick. An experience that was at once safe and yet disturbing, thought-provoking. Do we belong here, do we have a legitimate purpose, a necessary role, can we help make any difference – or shouldn’t we just stay at home and look to help there! Great questions.

Badistan IDP camp, one of several training scenarios organised by the ILS team.

Posted in Aid and Development