Tomorrow, Today - Self-Managed Abortion & Autonomy in Medicine with Dr. Leslie Hoggart

Episode Date: October 17, 2022

In this episode of Tomorrow, Today, we discuss self-managed abortions, medical biases in training, and the changes that are being demanded by medical students around abortion training and abortion care. How does the medical infrastructure in industrialized countries continue to fail people in need of abortion, and where does self-managed abortion fit into the conversation? Dr. Leslie Hoggart is Associate Head of School (research excellence) in the School of Health, Wellbeing and Social Care at the Open University as part of Oxford University. She specialises in qualitative research, and spent many years working in the qualitative research group at the Policy Studies Institute. Her research interests are focused on reproductive health, abortion policy and politics, teenage pregnancy and sexual health.

Welcome to Tomorrow Today, a podcast where we talk about tomorrow. But today, I'm your host, Nash Flynn, joined as always by Scooby-Doo. Scooby-Don't. Scooby-Don't. Scooby-Don't bring that shit in my house. Doctor Scooby-Done bring my shit into your house. Yes, and you'll say the entire name every time. Every single time.

Speaking of doctors. Yes. Sorry. You're like, hmm, I should move all of my keys as we start recording. Not before. I forgot. Not after, but during. We're recording.

I forgot. During the moment with the recording that's very focused on this silent room in which we can record silently. Silently. Together. So what else do we do together, Nash? Well, we do this podcast, which is about, I mean, today it's about abortion. Tonight we are talking about, not tonight. Tomorrow.

Tomorrow, even. Today we're talking about. Tomorrow we're talking about it. We're talking about abortion. So normally when we do these little intros, we like to have our personal experiences with the topic. So, Andy, what is your personal experience with abortion? You have one? I don't.

I had a near fear of needing an abortion for someone when I was younger. I feel like this is news for me. It might be. It wasn't you. I remember, like, that was, you know, being like a 16-year-old boy and not, and be like, babies deserve to live because you don't know any better. And then having that experience was like really a wake-up call of how am I going to raise this child if we can't have an abortion. Right.

And I remember being 16 and driving around the region trying to figure out what we were going to do. And yeah, I am pro-choice. Yes. And needless to say. I'm pro-abortion. Pro-bortion? Yes. Yes.

Definitely pro that. I've never had one. I don't know that I've known anyone that has told me that they've had one. and that's a pretty distinct difference. We'll actually talk about that in the episode. But yeah, no, I have two children. Yeah, I gave birth to those children, but they were choices, you know, which was nice. In regards to knowing people with abortions, I do have a number of folks that I know personally that have had abortions.

And the reaction to that discussion is very, I can say varied in how they engage with that experience. And I think that's really telling about our personality and our comfort level with it. Right. And that there's such diversity and consequently the reaction to their divulgence of that knowledge is also equally like varied because it's such a, despite it being such a common subject, it is still largely like not socially appropriate, nor is it something that like there's an easy answer because, you know, I think in 2022 we don't usually say sorry for that experience as much as. because of this understanding of like women empowerment or a fab empowerment, whatever term you want to use. And that makes it just in an attempt to be more comfortable with the subject matter and more affirming of the subject matter, we become less comfortable with it because it doesn't fit into a cultural norm anymore. Right. Right.

So in today's conversation with Dr. Leslie Hoggart, we talk a little bit about self-managed abortion, which is slightly different than just your regular going to the clinic. abortion. Or my case, just driving around in the middle of the night. Your fever dreams of abortion. Yeah. So this is managed at home, obviously, usually via medication. Actually, only via medication, I think. I mean, versus non-medication? Like, you call the mob and they take care of it for you? One of those? In my head, I was thinking wire hangers, flights of stairs. But we really don't advocate for those things because they're dangerous. So yes, this is a pill that you take and it, you know, I don't want to say it removes your pregnancy because that's not.

Does the thing. Yes. It does the thing. In today's episode, we're talking about abortion as a choice to end a pregnancy. Even though in the U.S., at least, we say abortion to also mean medically a miscarriage. So it's just the end of a pregnancy before term that does not result in a living fetus, maybe just a fetus. I'm not really sure on that one. Anyway, we're talking specifically today about the choice to end a pregnancy. Now, you could have asked Dr. Scooby, do not do that about what the proper medical term is. Would he know? He might. Doctor? He's not here. Oh, he left. Well, because he got infuriated that I didn't get his title right, probably. Yeah, probably. Damn it. Damn it, Nash. Cursed again. So today we're talking about abortion in the UK.

Now, the United Kingdom has had legal abortions via a de facto law from 1967, meaning that anything before 24 weeks that's at risk to the mother in either her physical or mental health, and that's the piece that basically makes abortion legal. They can terminate a pregnancy 24 weeks or before. After that point, it's at the risk of the mother's life. In Ireland, which is not the UK, totally different country. Very close to, physically, totally different country. Ireland, it wasn't legalized until 2018.

Kings. Catholics. That's the problem. Catholics. And what I love about Ireland finally legalizing abortion in 2018 is that this is the same country. Okay, so they did not, they have feelings about abortions because of Catholicism, but they refer to their entire country's civil war and breaking apart by a name that

sounds like what you would be getting an abortion for. Like, they literally call their civil war. the troubles, and that sounds like a 16-year-old pregnancy. The troubles is like the gurgles or something. See, I feel like it's something that like grands whispered. They're like, oh, she had the troubles, you know what I mean? Lina, it's like, oh, we understand. I like you're Irish, by the other.

It just slips in it. Settle. I can just hear my own grandmother definitely talking about somebody who got pregnant, like, and shouldn't have been pregnant and it was just the troubles, you know? That was not Bostonian enough. Sorry. Maureen would not approve. The thing is, I think she would.

So, anyway. The accent? No. Oh, well, maybe not the accent, but it was a reach anyways. So we're talking about abortion in the UK. It's been legal since 1967. Obviously, it is no longer universally federally legal in the United States at the time of this recording. I think about half the states are in.

I think it's about 70% of the population or so. I think about 50. It's either right above or right below 50%. that allows abortion right now. Yeah. And obviously there's a bunch of complicated pieces to that in terms of what parts of the country do not allow abortion or have extremely limited laws around abortion and how that is disproportionately impacting marginalized people.

Right. For those of you that don't know in the states, Roe v. Wade was our Supreme Court case that allowed for legal abortions. That was overturned by the Supreme Court earlier this year. in just a hallmark decision of American patriotism. Freedom is coursing through your veins. It's hard to sit here and be this free, you know? Yeah.

It's almost like a wait. Yeah, and one of the things I think that people don't really understand in the United States in engaging with this conversation with the UK is how our laws are structured and that our court cases are based in a different law system than the UK in terms of we have you can codify things and create laws and you can also set precedent and rovi way to was set on precedent and that concept is basically like we're going to defer to a previous court decision to make our decision and that's how a lot of american laws have been designed where it was like basically well this happened to joe farmer so i want the same thing that he got when this happened

to him basically what the court system is set up by it originally stems from the french a law system. And that's, you know, a much bigger and longer and convoluted conversation. But I think we struggle sometimes understanding why what was happening with Roe v. Wade is so uniquely American. And it's because of the way our laws are designed. And like there's, there's very good reason to criticize that because most of the world isn't like this. Yes, this is just uniquely American. The freedom just really, you know, we were like. DRIPS. It's got drip. As the kids. I have no idea what that means, but it sounds legitimate. But, you know, the UK has Parliament, so theirs was an act in 1967.

Also, Roe v. Wade is later than 1967, so 1973, I think, is Roe v. Wade. So America was already behind, and now we're more behind. Back-to-back champions. Yes. So we live in the state of Massachusetts where it is legal, and I believe it has been stated that they will always be legal here. I also recently found out that that there's a campaign to separate

the United States into smaller regionalized districts for which Boston would be the head of the Northeast. Not New York? No. It's run by Bostonians. Okay, that makes sense. Specifically, like, Matt Damon. Yeah, Matt Damon for president

is apparently like a rational response to everything happening. That's where we are now. We wanted Leonardo DiCaprio, but he's not from here. No, he's not. He just, It does a great Boston accent. It doesn't at all. So this episode, this interview was a fascinating chat about self-managed abortion.

So this is, again, the pill that you take. The study that Dr. Lizzie Hoggart was working on was whether the abortion system, the self-managed abortion system, was successful with and without patient support and how that support was provided to people. In our chat, we talk a little bit about the statistics of that, whether people liked it, and what the stigma around abortion really is. And that conversation, despite our laws being different, is basically the same across the pond.

So now you don't have to listen to it. Yes, you've heard me talk. No, I'm just kidding. You absolutely have to listen to it. There's an action. This is America. There is a gun to your head. Maybe two.

There are real facts in the episode that I'm not giving you right now. Possibly three. She's a doctor. That's what we're saying. That was the number one point. Four guns. Oh, I see. What did you think I was talking about?

Facts. So anyway, stay tuned for this fantastic chat about self-managed abortions. And of course, if you need more information about abortion, you can go to shoutyourabortion.com. They have some really, really great resources. And if you're struggling and you don't know where to go, 9-88 just became the mental health suicide hotline in the U.S. So if you're struggling and you need somebody to talk to you, that is always a great resource too. Today I've had the pleasure of sitting down with Professor Leslie Hoggart. She is the Associate Dean of Research and the Faculty of Well-Being, Education, and Languance.

languages at the Open University. She specializes in qualitative research, focusing on sexual health and abortion. Professor Hoggart, thank you so much for coming on. Can you tell us a little bit about your background? My pleasure to be with you today. Thank you very much for inviting me. So I've been an academic and a researcher for many, many years now and gradually begun to specialize sexual health, and then abortion, policy, politics, and primarily researching around experiences of abortion in the UK, not just in the UK, but mainly in the UK. That's fantastic. I think it's one of those areas that we definitely really, really need right now in modern times, which is unfortunate. Now, you've written quite extensively on abortion

from a number of perspectives, as you say, and given what's happened in the past year here in the US, I think that work is becoming more and more important. So I wanted to start the conversation with a research project you'd been involved in that recently came out, the focus on medical students and their readiness working around a fairly common medical procedure. Can you explain a bit about what brought you to surveying medical students if you'd expected the results you got and why those results are significant? Yeah, well, this was a really, really interesting project. And it was actually a project that was undertaken by medical students at University of College London in partnership with one

of the academics there, Jane Kavanaugh, and I was, Jane asked me to be to be involved because she knew of my research and she knew that I would be interested. So it really came about because what we know when we do research on people who support abortion experiences in the UK is that many have very poor interactions with medical professionals, that they may be, their motivations for wanting to have an abortion may be questioned, that the medical professional they're coming into contact with may well be very obstructive and make it difficult for them to even access an abortion. And we'll often make them feel quite stigmatized for wanting an abortion. And we also know that from other research, that the way that our medical students in the UK

are educated around abortion is very patchy. So it's quite rare to have, you know, a good and a holistic education on abortion. And, you know, the issues around abortion in the UK, it's like a bit of an optional extra, really. Whereas we thought it should be, you know, it should be part of a medical curriculum. So that was the motivation for starting to do the research with medical students. Do you want me to say about what we found? or have you got any sort of other questions on the motivation? Yeah, no, please. I'd love to hear about the results.

And if any of them were surprising, I sure it was a little disappointing more than surprising. Yeah. Well, actually, because the research wasn't so much finding out, we weren't surprised to find out that the quality of education was very variable. We weren't surprised to find that out at all. But what was really good about the research was, so this was, so this was. was with medical students, medical students really thought that their education should prepare them to be competent practitioners in the area of abortion. So that was a really strong finding in the research. They thought that they should be able and coached in many ways to, in order to provide non-stigmatizing care. And they felt that because the topic is seen as sensitive, they thought that

that was a reason to make that all the more important rather than a reason not to sort of go there and not to have it within their curriculum. So, you know, I thought that was really encouraging that that's what medical students wanted. So now all we've got to do is to put a little bit of pressure on the medical schools to make that happen really. Yeah, no, that's great. I actually, I'm surprised, I guess, in a way, but also I guess I'm unsurprised. So these are medical students. So they're sort of up and coming. They're a little bit younger, I would assume, just based on, you know, going to school. So maybe that isn't surprising, but this isn't the first time that you've pointed out that the medical establishment is basically failing women in these abortion services, not medical students, but actual practitioners.

And you've also criticized some terms like repeat abortions, which you say stigmatize women who experience more than one abortion. So the consistency in your work really seems to be that without fundamental change around the attitudes of health professionals towards abortion and receiving. services. Abortion care will just continue to be stigmatized. Yes. Yes. I think so. I think, though, that what I want to do is differentiate between abortion providers as health professionals. The abortion providers that we have in the UK dedicated providers do a lot of work around challenging stigma and provide a really brilliant service for people. Where people who want an abortion come unstuck and face difficulties is in all the other health professionals that they might come into contact with. So, I mean, the way that our health service works in the UK is a bit

different from many other countries. So what happens here is that your first port of call for pretty much anything to do with health is to go to a general practitioner. And the general practitioner is like your family doctor. So if you've got a cold, you go there, if you've got, you know, if you've got something serious, you first go to the doctor and they then refer you on. In the research, it was really interested. One of the students who we interviewed, she wanted to become a GP and she said, I know I'm going to see lots of people who would want to have an abortion. And I know I'm going to see very few who will have an ectopic pregnancy, yet we've had so much education on a topic pregnancy

and I would have no idea what to do when the first person walks into my office and says I want an abortion. So, you know, they're not prepared and they can be, yeah, they can be very obstructive, just making it very difficult for people to get through all the hoops that they need to do. It's quite ironic because people now don't need to go to the GP,

they don't need to go to their general practitioner, they can just pick up a telephone and call one of the abortion providers and then go that route. But still, a lot of people don't realize that and their automatic first port call is the general practitioner. Wow. It's a little similar of a situation in the U.S. I'm not sure abortion specifically, but we do have the GP system where you're supposed to go through your primary doctor. I mean, we do have the Planned Parenthood clinics, which sort of operate the same as the number would in the UK. So it is a bit similar. So I know you've talked about including abortion as part of a normal routine sexual reproductive health, but that appropriate support and structural change are

essential for the normalization to become embedded. So in addition to having medical students sort of pushing from the inside to get access to training to how to do these things, what can we do outside of this industry to help change this perception? I think there's a role for everybody in terms of trying to normalize abortion and challenging abortion stigma. And the one thing about abortion stigma that is that we can all actually chip away at is the secrecy and silence around having an abortion. So it becomes a vicious circle. So in the UK, approximately one in three women will have an abortion during their lifetime. That is complete news to most people who become pregnant when they don't want to be and then are thinking about having an abortion.

they have absolutely an idea that it's as common as that, that it's as normal and ordinary as that. And a lot of people that we interview in our studies, when they're facing a pregnancy that they want to end, and they start to tell maybe the odd friend, lots of people don't tell anybody, actually, but if they maybe confide in one friend or maybe their mother or sister or aunt if they're able to,

then that person will very often say, oh, yes, I actually had an abortion. And it was something that was a big secret. Wow. So this is something that really feeds into abortion stigma and makes people feel that it's something to be shameful of and that they will keep, they will then go on to keep their secret afterwards. And it just keeps going self-perpetuating, really. So I think the more that we can encourage people to tell their stories, to, you know, there's a lot of storytelling and publicity about abortion in the UK. Every once in a while, including celebrities,

you know, lots of people will stand up and say, yes, I've had an abortion, and what's the problem with that? So the more of that we can do, and the more public engagement, educational materials, et cetera, et cetera, and particularly going into schools. I've done a lot of work with an organization called Brooke, young people, and they produce teaching materials for teachers. And we've produced a whole module on unintended pregnancy and abortion. So, you know, if you start sort of trying to break it down as early as possible, then that's really helpful. Yeah. And I think to your point,

combating some of the other things that are part of abortion, especially in the United States where, you know, we have people saying, oh, it's just women, you know, using it to not have babies like birth control. I think it's all the more important to get the information that's accurate and supported by data out there. Now, when you say one in three, is that women who are seeking to terminate a pregnancy, or does that also include women who miscarry? No, that is women who are seeking to terminate. That doesn't include miscarriage. Wow. So that's a... No. And you mentioned repeat abortion, that phrase repeat abortion, which is so stigmatizing. So one in three women will have an abortion during their reproductive lifetime.

Of those, one in three will have a second or further, we'll have a further abortion. Yeah. So it really is way more ordinary and normal than anybody could possibly think it is. Yeah. Wow. That's that's very, very common. I'm actually blown away by that number. That's very common. I assumed, because we use the term abortion. I'm not sure if it's medical usage in the UK as well, but we use the term abortion medically also to refer to miscarriages. So not actively done by the mother, but actively done by the body or to save the lives. we use that as an umbrella term. So I'm surprised that this is one in three people choosing for this path. So that number would obviously be higher if we were including just terminated pregnancies in that. That's, wow. Oh, yes. Yes. That's a much, much higher thing. Very common. We include what we term as miscarriages or sometimes spontaneous abortions. We use that terminology as

well. But I think it's quite helpful to distinguish between miscarriage and abortion. I agree. Yes. I'm blown away by that statistic because it's all the more important that your medical students are being like, we have to figure out how to do this procedure more than aptopic pregnancies or ectopic pregnancies and on other things that aren't as common as a one in three abortion rate. Wow, that's astonishing. Yes. I want to focus a little bit on a recent paper you published where you talk about the concept of self-managed abortion. So can you talk a little bit about what is self-managed abortion is? Yeah. So self-managed abortion is something that has been happening for many, many years now. Basically, it means ending a pregnancy yourself without the formal supervision of a healthcare

professional. So it would normally, so it would be a medical, or I think in the US you call them medication abortion, and it doesn't require surgery. You take two lots of medication, Miffy Pristone and then Miser-Prostol, and you can do that by yourself at home. And according to the World Health Organization, this is perfectly safe up to 12 weeks of pregnancy. There's whole lots of terminology that are also used, like at-home abortion or pills through the post. But I think self-managed abortion is generally taken to be the best term to use. to describe this process. Okay.

And that's, is that available worldwide? Do you know? It is available worldwide, but it's not, it's not legal everywhere. You know, it's, it's, it's, it's available. In countries where abortion is illegal, then there are ways in which people can get their hands on this medication. and the availability of the medication is really opening up the possibility for people to exercise their reproductive control, even in situations where abortion is illegal.

And the fact that it's without the formal supervision of a healthcare professional means that people can be supported with an accompaniment model, or we might call abortion doulas, which we have some, we have some abortion dulus in Northern Ireland, where the legal regime is very different to the rest of the UK. So, yeah, it really opens it up for women to take that control into their own hands. Yeah, yeah, definitely. So what's particularly interesting about this paper is that there are psychological impacts from this self-managed abortion from the comfort of home. So 80% of people who did this at home abortion were satisfied with the process and 17% were not. In the paper, you wrote that this echoes an earlier study based on web-based provision.

So women accessing services provided by health care staff reported high rates of satisfaction, but those for whom medical guidance and reassurance were lacking during the abortion reported some distress. So what's going on here? Okay. So this is quite complicated. But first of all, I do want to say that this is quite. a high threshold that we're looking for of satisfaction. So the minority of women who maybe say they're not completely satisfied, it might would probably still prefer, they would definitely

still prefer to have a medical abortion as opposed to not having access to that. It's just if you would, you might think about would you like to have another medical abortion or do you think another time you would prefer to have a surgical abortion? So it's like that. that, you know, so not being satisfied doesn't mean that it's not something that they welcome and have access to. I think it's really important to make that clear. But medical abortion can be quite painful. It can make you feel quite poorly. And sometimes people don't feel prepared for that. So the reason why we emphasize supported self-managed abortion in the paper is because we see that in the research that we've done and others have done, that with the women, and in these pieces of research it is women who are not so satisfied are most likely to be women who don't have the support measures in place. They're not in regular contact with their provider or they've been a bit isolated,

particularly during COVID. But people who have got their support in place, they're keeping contact with the provider, they can call them up and say, God, this is really, really painful. Is that normal? And they might say, yes, it can be painful, but take this medication and you'll feel better. This is all makes a huge difference to how you would feel about going through something like that. by yourself at home. So we weren't seeking to,

in these research findings, it was very clear that the majority of women did welcome and were very happy with having their self-managed abortion at home. For the few who weren't, it was very specific reasons connected with pain, feeling ill, feeling isolated, and feeling anxious that things weren't

maybe going as they should be. and extra support during that process would make all the difference. That's what we think. I know this is putting you on the spot for some speculation, but do you think that if we had changed, you know, some of how society feels about abortion? If we talked about it more, if we knew it was more common, do you think those 17% who found some part of this unsatisfactory or difficult

would have gone through this process a bit better? Yes, absolutely. I've got no doubt about that. talk. It is slightly speculative, obviously, but we've interviewed a lot of these women in debt. And you can see that a lot of their dissatisfaction is to do with their bodily discomfort and pain, which can be ameliorated, and it's definitely to do with feeling isolated and thinking that you're doing something that's secret and shameful as well doesn't help. doesn't it? So, you know, you're not going to reach out to people. You're not going to realize that this is, this is quite a normal thing. Like, you have your wisdom teeth back, you know it's going to be really painful and you're going to be putting up with it and you're going to be in pain for, I don't know how long. And you might reach out to people and talk to them about how you're in, you're in pain. But if you're having an abortion, you're much less likely to do that. So I do think that, yeah, what we've been talking about and what you asked me about earlier on is also.

so really, really important for making self-managed abortion easier and more acceptable for women. Absolutely. So is there any evidence that you've seen suggesting that self-managed abortions increased or decreased someone's decision to get an abortion? I don't think. I don't, I haven't seen anything in the research to, to suggest that. But what we have noticed is just, particularly during COVID, a lot of relief. that they are able to have an abortion at home and not go to a clinic and as far as possible to be in control of the process. But I do expect that as self-managed medical abortion becomes more common,

that people will choose. I mean, it is already by far the most popular choice in the UK in the first trimester. So, you know, I do expect that to continue. that's fantastic so i'm going to end on on this and i'm going to allow you to speculate on this one also so i'm sure you know in the u.s several months ago roe v wade was overturned by our supreme court and that meant that as it rolled out as it was overturned about 50 percent of the united states lost access to easy abortion care to legal abortion care which means that 50 percent of us already have

no route to get an abortion and the other 50 percent of us are largely distressed and anxious about whether our access will continue when we want to protect the access of people who have recently lost it. So can you talk a little bit about, you know, anything you feel on the U.S. politics? Can you, you know, speak directly to people who may be facing some severe anxiety on this topic or somebody out there who found themselves in a situation and is now trying to decide what their next steps are? Yes. So, I mean, first of all, it's just, it goes about saying just dreadful, really awful. And, you know, we have a lot of solidarity with people in the US who are being affected in this awful way. But what I would say is that

it's very, very different now than it was at the time of Roe v. Wade. So we do have self-managed medical abortion. And that does put, that does put the potential to arrange a abortion and manage your own abortion in people's own hands. And I know that already there are a whole number of networks that are enabling that in the US. So I would say, you know, find a supplier, find a provider that you trust, keep in contact with a provider and just go about doing what you need to do. Whether abortion is legal or illegal, we all know that it doesn't stop abortion. It just makes it less safe if it's illegal. But the potential of self-managed medical abortion is actually breaking that down as well. So even in

illegal situations, if people get the right medication and they follow the guidance, then of self-managed medical abortion is perfectly safe. And it also gives the potential for disobedience as well. Exactly. Do some crime. Yeah. I mean, it's hard, hard times. But I can see, and I do hear, that there's a lot of mobilization going on. And so much is happening in the US to make sure that people still have access to abortion. that it's not as horrendous as it is, it's not as bad as it could be.

Right, exactly. You know, we do have the benefit of the internet too where we can easily spread information and talk about having had abortions and how to get access to them. And, you know, I've seen quite a few people reaching out and saying, if you need to come stay with me, I live in a state where abortion is legal, just saying. So that has been very, very good. And if anybody needs a resource at the time of this listening,

shout your abortion.com is an excellent resource. for people in the States right now. Yes, that's a brilliant slide. Yeah. Yeah. Any last thoughts, Dr. Hoggard? I don't think so. I don't think so.

I just think that, you know, the self-managed medical abortion is so important right now. It's being done without medical support. If you can get medical support or well and good, but you don't, it's not an essential. You know, you can be supported by feminist activists, you can be supported by doulers, you can be accompanied. There's a whole number of different ways. of getting hold of that. And, um, you know, there's hotlines and there's activists and hopefully maybe massachusetts, but, um, yeah, so, so just, just keep at it. Yeah. Thank you so much for joining us. We really appreciate it. No, thank you for inviting this. It's been great.