The failure of family planning

The UK has a terrible record of unwanted pregnancies, and the abortion rate continues to rise, reports Sally Dawson

The news that one in five pregnancies now ends in abortion provoked widespread despair last December.Although it varies across England and Wales, roughly one in three women will now have an abortion during their reproductive life. Although the abortion rates fell slightly during the early 1990s, they have continued to rise since 1995. And Britain holds the dubious record of having the highest teenage pregnancy rate for 15-19 year olds in Western Europe.Whatever your ideological perspective, whether pro-choice or pro-life, such a high level of unwanted pregnancy is clearly not a success - either in social or economic terms. It is a clear and catastrophic failure of the family planning system.

The government has made a degree of progress in addressing this problem, setting-up a Teenage Pregnancy Unit in 1999 to implement a Social Exclusion Unit report on teenage pregnancy. It recorded a fall last year for the second successive year for under 18s - although the under 16 pregnancy rate remained relatively static at 8.3 conceptions per 1,000.

Although it was estimated that over 4,000 teenage pregnancies had been prevented since the unit's inception, the highest number of abortions, says the British Pregnancy Advisory Service, are actually amongst women aged 20-24.As Ian Jones, BPAS Chief Executive, says "it is a problem with adults not just teenagers".The word "contraception" is notably absent from the five key aims of the government's 2001 Sexual Health Strategy. Giving evidence to the Health Select Committee in July last year, contraception and reproductive health consultant Dr Sarah Randall, said: "Four of the aims are to do with HIV and STIs and one is to do with abortion. Contraception just seems to have disappeared. After all, if you had good contraception we would not be here to keep out abortions."

There are a number of ways to access contraception in the UK. Unlike some of our European neighbours - the Republic of Ireland for instance - the pill is available free on prescription regardless of income. This can be obtained from a GP or from a Family Planning Clinic which also offers the kind of specialist advice that a GP may not have the time or knowledge to give. The morning after pill is more widely available as it can be purchased over the counter in chemists - although few women are aware that it can be successfully taken up to 72 hours after sex.

Family planning specialists believe that the system is too fragmented, with confusion over what is offered where. This problem could be additionally exacerbated by the government's new GP contracts which, if ratified in April, contain proposals whereby overstretched practices could decide to opt out of providing contraceptive services.But the basic problem, the health committee was told by Anne Weyman, the Chief Executive of the Family Planning Association, is that contraceptive services are "over-loaded".

Frequently seen as the "soft option" for expenditure cuts, clinics are often perceived as expendable because GPs also provide contraceptive services - although these can be very limited. "We know that women are not being offered very effective methods of contraception such as intra-uterine systems, implants and other long-acting methods because they are seen as too expensive," she said. "But if you then look at other services that have to come into play - like abortion if the contraception the woman uses is not successful - then they are cost-effective."

An additional problem, said Dr Kate Guthrie, a sexual health consultant, was that young people were simply ignorant of the existence of family planning services: "Young people have to know where to go. It is one of the best kept secrets from young people. You really have to work quite hard if you are young to get information or access to services. I have got teenage children. They say: 'Our friends come to ask us, and if we were not your children we would not know where to go either.'"

The pregnancy rate is not just contraceptive failure, said Dr Guthrie, "it goes back to education in primary schools, youth clubs, in the home, on television and everything else".

And starting sex education at a young enough age was a key issue, argued Weyman, including primary school provision: "The guidance that was issued from the Department of Education focuses on the transition year [children between 10 and 11]. By that age we know that children have picked up a great deal of information and misinformation about sex and relationships. If you do not start early, you are losing the opportunity to get across appropriate messages to them in a way that is suitable for their age and experience."This view is eschewed by family campaigners who believe that this kind of education only serves to encourage young people to experiment with sex at an even earlier age, robbing them of their "childhood innocence".

Weyman acknowledged that this view was a controversial one: "The moment you start talking about providing sex education to younger children you get a whole hysterical outburst in the media."

A culture change was needed, she said, so teachers were no longer "pilloried in their local press" for providing sex education to children.A teacher-training scheme, pioneered by Exeter University, which apparently aimed to cut levels of promiscuity by "encouraging pupils to discover 'levels of intimacy' including oral sex, instead of sexual intercourse" recently generated front-page headlines, the Times leading with "Government urges under-16s to experiment with oral sex".

Although the programme manager, John Rees, defended the course, saying that it made it clear that it was acceptable "simply to hold hands", a teacher is quoted as saying: "There is no framework for talking about responsibility or the emotional side of relationships. By following this course, I feel that teachers are implicitly supporting under-age sexual activity."

The media may also have a wider part to play in the UK abortion statistics. During the early 1990s the abortion rate among young women did fall slightly, but then subsequently rose again between 1995 and 1996. This increase is thought to have been the result of a "pill scare", says the Office of National Statistics, after the Committee on Safety of Medicines warned that several brands of the contraceptive pill carried an increased risk of thrombosis. "This warning is believed to have contributed to an increase in conceptions and a related increase in abortions in 1996, particularly among young women as they were more likely to have been using the pill. Following this pill scare the abortion rates did not fall back to the 1995 level, but have continued to rise. There have been subsequent warnings about the links between the contraceptive pill and thrombosis."

These high profile warnings often fail to note that the incidence of thrombosis is actually higher amongst pregnant women, so young women who stop taking their oral contraceptives during a "pill scare" and subsequently become pregnant are actually more at risk of the condition than if they had continued to take their pill, albeit switching to another brand after taking advice from their doctor.

Aside from factors influencing contraceptive failure, the reasons why an adult pregnancy ends in abortion are complex, with failing relationships and career pressures - such as childcare provision - playing at least some part in the choice to end a pregnancy.

It is also significant, say the Society for the Protection of the Unborn Child (SPUC), that over 75 per cent of abortions are conducted on single women. "The factors which tend to raise the incidence of abortion among single mothers include government policy, the attitude of some health providers, lack of commitment from the baby's father and economic pressures," it says. "British abortion practice amounts to savage discrimination against children conceived outside marriage, and is reflected in serious long-term harm to women - especially in its impact on psychological well-being."

The economic factors in choosing to end an pregnancy may be well founded. The ONS statistics show that women in London were the most likely to abort a pregnancy with a 32.5 per cent termination rate compared to the East of England where only 19.1 per cent of pregnancies are ended.

However abortion is not only an issue for single women. The BPAS estimates that one woman in five who has had an abortion is married and 47 per cent of women who have abortions have at least one child already. But whether this reflects the cost of living in the capital or cultural attitudes towards careers and motherhood is unclear.

The government is launching a Sexual Health Week from 5-10 August to improve the country's sexual health. Both women and men have more choice in contraception than ever. But unless the government addresses why the family planning system is failing, we may see a continued rise in the abortion rate.

"This reflects in what has become a medical problem, but it is only medical because we mop up," said Dr Guthrie. "It is a cultural and attitudinal problem. As medical providers, we are left mopping up what has gone wrong."