Category Archives: health policy

Control of reproduction

I’ve been watching with horror and disbelief the debates in the US state of Virginia about a proposed new federal law which would mandate that all women wishing to have an abortion, regardless of the reason, would first have to have an ultrasound scan. Given that many abortions take place before 12 weeks, when it is difficult to detect a foetus using transabdominal ultrasound, this effectively mandates the use of transvaginal ultrasound, a considerably more invasive procedure, whether or not the woman consents to this. There has been a lot of debate about how this wrests control of reproductive choices from women, referred to by some commentators as “state-sanctioned rape”, and in effect “dictating a medical procedure to a physician”. There are a couple of articles here and here with more detail.

Meanwhile, in Hungary, where in 2011 the government tried to introduce anti-abortion legislation using EU funds earmarked for gender equality projects (see here and here), a renowned obstetrician and midwife who has for some years championed home births in Hungary had her appeal against imprisonment not only refused, but her ban on practice lengthened. There is background to the case of Dr Agnes Gereb here and a Guardian report of her unsuccessful appeal here. Home birth is not illegal in Hungary; however it appears that legislators are fearful of an intervention which, in the case of women of low obstetric risk, is at least as safe (and in many cases arguably safer) than hospital births, and this state-sanctioned censuring of the choice to give birth at home is another attempt to reign in choice and increase control over reproduction.

These depressing stories put me in mind of my PhD research, which looked at sexual and reproductive health in Romania and Moldova. Romania in particular had particularly repressive policies around reproduction during the communist era, particularly under Ceausescu – from 1966 abortions were outlawed in all but certain restrictive circumstances, and whilst not banned all methods of contraception were very difficult to obtain, and propaganda against hormonal contraception in particular was so strong and all-pervasive that more than two decades after the end of Ceausescu’s regime in Romania there is still a deep-seated suspicion of it, amongst both public and the medical profession. Women were subject to compulsory gynaecological examinations, doctors and women performing or requesting abortions risked imprisonment and official figures suggest that between 1966-1989 nearly 10,000 women died from the complications from illegal abortions (the real figure is undoubtedly higher, as many deaths will have been illictly recorded as being from other reasons). One of the legacies of this state-sanctioned interference in women’s fertility and reproduction is an ongoing suspicion in Romania of any governmental attempts to promote any national campaign relating to sexual and reproductive health (a recent example would be the disastrous and failed campaign in 2009 to vaccinate school girls against Human Papilloma Virus).

I would recommend anybody who is interested in the consequences of extreme pronatalist and anti-choice legislation read Gail Kligman’s The Politics of Duplicity. This is a masterly, seminal book about Romanian reproductive policy under Ceausescu which details the inevitable outcome of banning abortion, making contraception in effect unavailable, and seeking to control fertility and reproduction so ruthlessly. Policy makers in Virginia in particular, but also elsewhere including Hungary, would do well to learn its lessons.

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Nurse bashing

Over the last couple of days there has been considerable coverage of David Cameron’s “brave attack” on the sacred cow of nursing (outlined by the Guardian here). “Brave” because, as Dave tells us, despite the fact that the “vast majority” of nurses are doing a marvellous job, successive governments have “lack[ed] the bravery to tackle the issue” (“the issue”, apparently, being “the “real problem” with nursing in the UK”). Er, run that by me again? ….. Apparently the solution to this is hourly ward rounds and patients inspecting hospitals, and a reduction in paperwork (and though I am no fan of excessive bureaucracy I am yet to hear about how we are supposed to evidence the work we do, to managers, funders or indeed courts, or hand on work to other staff, without the paperwork).

I’m not going to go on about one of my particular bugbears about Cameron’s pronouncements about nursing, the fact that he always seems to equate nursing with hospitals/wards (see my previous post after the November 30th strike for more on that) which drives me up the wall. Nor am I going to go on about how all nurses are wonderful, of course some are better than others as in any profession. There have been some horrific cases highlighted in the media of individual nurses working way outside the bounds of our Code of Conduct, up to and including the unlawful killing of patients. As there have been with doctors (Shipman, anyone?), and hospital wide failings have also been widely reported (the example of Mid Staffordshire Hospital being the most obvious recent example; hospitals this side of the border have also not been immune). It does worry, not to mention really annoy me, though, that nurses as a profession are singled out like this as responsible for care failings when health care is not only multi-disciplinary but also subject to the political whims of the day. I will be interested to see what the leaders in the profession (chief nurses, RCN, union leaders and others) have to say about this and how vigorously they will defend us. I can’t for a minute imagine the BMA staying silent if this type of attack was made on doctors as a profession.

I am also concerned at the ‘one size fits all’ tone of Cameron’s so-called solution. What has clearly worked well in Salford (from where Cameron proposed the hourly ward round; I wonder if he had thought of that before or if he just heard about it there and decided on the spot that it was the answer) may or may not work elsewhere. Staffing levels, profile of patients, number of patients per nurse, availability of appropriate equipment, support from management*, etc, all differ, so the implications for the working day of staff undertaking a daily ward round are very different from one workplace to the next. Individuals and communities vary, and ‘one size fits all’ does not and cannot apply, particularly in health care where the experience of both patient and nurse varies so much from day to day.

In qualitative research we are careful to say that our work is largely not generalisable (although the more research is done, the wider the net can be cast in terms of identifying similarities) beyond the group/population studied. Some would suggest this is a weakness, but I would argue that it could be a strength, in that it enables policy informed by research to be truly responsive at a more local level rather than reactionary. With my researcher hat on, I would like to see research done at local level to identify what are the specific issues which arise in that particular health care setting, and (crucially) involving the staff as well as patients/clients in identifying what can be done practically to build on good work and address limitations/poor practices. I realise that this is idealistic and funding for such research and consultation is limited; however I am not at all convinced that a ‘one size fits all’ approach as advocated here by Cameron is an appropriate or sustainable alternative.

* don’t get me started!!! I do apologise for the rant, I will try very hard not to rant next time! 🙂