Good old fashioned talking to patients

Women who have repeat terminations of pregnancy

Louise Massey

Background• In 2011, 36% of all terminations in England

and Wales were to women who have ever had a previous termination (risen since 2001 31%)

• In 2011, in Wales, 22% of women under the age of 25 having a termination had ever had a previous termination (varies with area in Wales 12-27%) – Performance indicator • Rate increases with age

Abortion rate is decreasing slightly having peaked in 2007

THE NUMBER OF TERMINATIONS IS DECLINING BUT THE PROPORTION

OF REPEATS IS INCREASING

Other trends

1. Over the last 10 years an increasing proportion of abortions have taken place at earlier gestations

Other trends1. Over the last 10 years an increasing

proportion of abortions have taken place at earlier gestations

2. A greater proportion of abortions have been funded by the NHS, and done by the independent sector

Other trends1. Over the last 10 years an increasing

proportion of abortions have taken place at earlier gestations

2. A greater proportion of abortions have been funded by the NHS, and done by the independent sector

3. Joining up of abortion and contraception services, an increase in the provision of Long Acting Reversible Contraception (RCOG guidance since 2000)

What am i talking about?• Attempts to define repeat termination, but no

consensus. For example, those women who had ever had a previous abortion• Gispert et al defined as 2 terminations in 2 years

or more than one termination in a 12 month period

• 4th or subsequent top (6th request is the most I have encountered)

Discussion point• Normalisation of up to 3 previous tops as it

seems like a frequent occurence• Do people have any thoughts about this ?

Why am I motivated to think about this?

• About 2 years ago we began to think about this issue in the service where I work

• Many of us felt upset, frustrated and exasperated to meet women in situations like this

• We felt that there must be something we could do to reduce their repeated angst (?self harm)

• We wanted to somehow identify women who were particularly vulnerable

What do we know from other authors?• More likely to be

– Black– Earlier sexual debut– Have left school earlier– Be living in rented accommodation– Be victims of domestic violence– Have a greater number of lifetime sexual partners– Have substance misuse issues– Be poor– Have had one or more adverse life event in the preceding

12 months (eg loss of job, home, relationship end)– In short, vulnerable women

It’s not just about contraception!• RCT Hum Reprod 2006; 21: 2296–2303

Schunmann and Glasier 2006• Women having a top were randomised to

receive specialist contraception counselling or usual care

• Followed up for 2 years

Results - Intervention Control

Uptake of contraception

271/316 115/297 P<0.001

Uptake of LARC contraception

141 78 P<0.001

% having repeat abortion within 2 years

14.6 10 P=0.267

Schunmann and Glasier 2006

Thoughts?

Our experience• Psychodynamic intervention by one Dr • Women requesting third or subsequent top• Individual counselling – contraception very

important• Review all pregnancies with the aim of

reflection

Repeat TOPs results Psychodynamic intervention

Usual Care

Number (%) of patients returning to request a repeat abortion within 2 years

7/82 (7.9%) 5/84 (5.6%)

Number (%) of patients having a LARC method at procedure

72/89 (80.9%) 64/89 (71.9%)

Some of it is just luck• Stone and Ingham. J Fam Plann Reprod Health

Care 2011;37:209–215. doi:10.1136/jfprhc-2011-000063

• “if provided with a contraceptive method with a typical user failure rate of 10% (i.e contraceptive pills or condoms), approximately 30% of women who attend for abortion will re present within 2 years”

Reasons for repeat terminations • Fecund• Genuine contraception difficulty• Vulnerable• Not motivated

A very fertile lady• AG was 37, had 5 children, had had 2 miscarriages and 3

abortions. First pregnancy was aged 16 “stupid kid” as a result of early UPSI. She then married at 18, and had 4 children and 2 miscarriages with her husband. The 4th child had a severe congenital heart defect and the amount of care involved caused great strain on the relationship and they split up. The child died and they got back together and had another child. Since then she has had 3 unplanned pregnancies with her husband all ended in abortion.

• She smokes and cannot use the pill, has had a spontaneous explusion of the coil and had a broken condom and used the morning after pill on one occasion. He refuses vasectomy

Genuine difficulties with contraception• Yvette, aged 32 came requesting her 4th termination. • First top aged 17 with an out of control partner.

Finished relationship. Using pill• Second aged 21 with Dan who later became her

husband. Using copper coil – fell out• Third aged 31 with Dan (then married and 2 children

later) used injection and was a week late getting repeat injection

• She had had her most recent termination 8 months ago. Dan had vasectomy after last top and was given all clear

Vulnerable• Jo aged 28, requesting 3rd top.• First aged 15, sexually abused by foster carer. Did not

tell anyone who father was• Second aged 21, planned pregnancy with John who

she then discovered was cheating on her with her best friend

• Third with Sean, known 8 months, previous conviction for GBH to ex wife. Locks her in the flat. Goes missing for days. Presented as someone leaving a violent situation

• Rang to cancel top just before op, no further contact

Romantic – wants to have a baby with a nice man

• Seran aged 28 requests 4th top. Educated. Well paid job.• First top aged 17, no partic guy, on pill• Second and third with Andy, “did not try to stop

pregnancy” but he did not react positively to the news• 4th, younger boyfriend Guy, same scenario supposed to be

using pill. Thought his reaction to news was immature• Tearful, but happy to be asked about it. Appeared

motivated to change. Not been asked about reasons before

Not motivated• Request for 5th top “so embarrassed” “can’t

believe it keeps happening to me”• Didn’t fancy a coil• Heard bad things about the implant• Might put on weight with injection• “I think I’ll stick with the pill”

Summary• Some common characteristics• All individual women• All individual pregnancies comprising a

chapter– To find out there has to be a spirit of enquiry

• Yes, persevere with contraception as may be like any other behaviour change issue eg smoking– Some women can’t get over their resentment.