An Interview with Dr. Abigail Aiken – Part 2

Abigail Aiken trained in clinical medicine at the University of Cambridge, before completing an MPH at Harvard School of Public Health, a PhD in public policy at the University of Texas at Austin, and a post-doc at the Office of Population Research at Princeton. She is now assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. Aiken is a new associate editor of BMJ SRH.



Kate Womersley, BMJ SRH’s social media editor, caught up with Aiken to hear about the current political challenges to the field, Aiken’s upbringing in Northern Ireland and her vision for research in sexual and reproductive health that speaks to the public.

**Read part 1 of the interview here**


How do you see the field of sexual and reproductive health today in 2018?

Since I’ve been in the field, ten years now, it’s been really exciting to see changes. We have many more disciplines engaged. Many clinicians have been interested in these issues for a long time, and have been able to address them in clinical practice as well as through research. But now we have people in sociology, public affairs, and public health – all working together. I really like to see interdisciplinary collaboration. We also have the reproductive justice element which has been around for a long time, but only made it’s way into mainstream clinical and sociological conversations of late. Reproductive justice is particularly important because it enables us to understand who really loses out and suffers when laws restricting access to contraception and abortion are allowed to go unchecked.

We have become a lot richer and more visible as a field, and will continue to do so with the arrival of new journals like BMJ SRH, to make sure that the research really gets out there to people and is expressed in a way that allows the public to understand the messages. There is usually a barrier: “Oh that’s academic research, , it’s going to be for the doctors.” But the field has realized how important it is to connect to people’s personal experiences in the research, as well as numbers. You need to be able to make generalizations, which only robust quantitative studies can provide, but you also need studies that people can really connect with so they can see an issue in terms of real-life experiences.

One of the most important developments in our field is partnerships that have developed between research and practice. You see many researchers working closely with healthcare professionals, public health organizations, and policy think tanks to answer the most pressing questions that affect real-life access to and quality of reproductive healthcare.

Do you feel that the questions and challenges are particularly urgent right now in our political present?

If you look at the historical trajectory – the U.S. and Ireland are the contexts I know best – there is definitely an urgency right now. In the US, we have seen challenges to abortion access ever since 1973 when Roe v. Wade was handed down. But challenges have become much more intense. Also the public conversation has really shifted. Back when the Hyde amendment stopped Medicaid funding for abortion, which came in 1976 three years after Roe v. Wade, it really compromised access for women of low-income at the time. It’s not as though this all started happening yesterday. But if you look at the rate of new pieces of restrictive legislation being enacted, that has increased dramatically recently. I think part of the reasons it’s so important we talk about this and produce research to engage with this question right now, is that we have an opening in the public attention cycle. That’s something people in public policy talk about––it means that there is a window to really impact the current trajectory of policy.

The case for urgency is also there in Ireland as we see a possible referendum approaching on the Eighth Amendment. Also in Northern Ireland, where we see MPs like Stella Creasy’s campaign for funding of abortion on the NHS for women who travel to England, you have a window when people pay attention and a difference can be made in public policy. This window is something as academics we often don’t think about. But if you’re engaged in public affairs you know that you have an opportunity to make a difference by bringing new evidence to the debate, and you have to try and respond to that.

How did your upbringing in Northern Ireland shape your research interests?

I was living in Northern Ireland at a time when there was, for example, no Women on Web. There was no way to access abortion care. There was very little taught in schools about sex education, about what sex was, or about contraception. I had no idea how I would get contraception if I needed it. My mum was very much a person who was supportive of reproductive rights, and was very progressive for her time (1940s) and for where she was living. But I remember her saying to me as a teenager, “You’ll do many things, but please, whatever you do, don’t get pregnant. That’s one thing I can’t help you with. We would have to travel, we wouldn’t have the resources, we wouldn’t be able to do that without telling people.”

I grew up in an environment where I was very aware of the fact that being female and being able to get pregnant put you in a situation that was different from men. I have always been very influenced by that unfairness. I felt from the start that this was an issue I was interested in tackling, trying to understand why things are this way, and what we can do about it.

For those who aren’t well versed in changes since the 1980s, and the NHS’ recent decision to offer terminations to Northern Irish women, could you give a potted history of what’s happened, and what hasn’t?

When the Abortion Act came in 1967 to the rest of the UK, Northern Ireland did have a chance to enact it, but they decided not to. They said, “We’re not going to touch that.” It was with the dawn of organizations like Women on Web sailing a boat to Ireland, and working with the activist groups on the ground in both the South and the North, that suddenly an online option was available to people. Others started saying, “We’re going to talk about this.” That’s been almost unbelievable change.

When I was living there in the 1980s, 1990s and early 2000’s, nobody would ever have talked about abortion. It wasn’t something you saw in the newspapers. It was maybe talked about only in the most closed groups, and only then in a very negative and sad way.

The biggest change we have seen has not really been a policy or political change; it’s been the groundswell of activism and a movement of women in Northern Ireland who are now speaking out about the fact that abortion is happening and can’t be ignored anymore. We don’t have the same rights as women in the rest of the U.K., even though we’re a part of it. That has led to the only actual policy change in years in Northern Ireland: that women who travel will hopefully be able to get their procedure covered by the NHS, similar to a woman who lives in England who is NHS-eligible.

But how that is actually going to play out is not yet clear. Although the policy is there in theory – it’s not been stated how those abortions are going to be commissioned and paid for. You still have the issue that travel needs to be paid for, which has not changed under the new rules.

How has your expertise in the Northern Ireland situation prepared you for your research in America? Are there interesting continuities and differences?

There really are. It’s very interesting to me because when I first came to the U.S. in 2009, the situation regarding abortion or any other reproductive healthcare was not as bad as it is now. Over the past few years it has become obvious to me that if you look at a woman in Northern Ireland and a woman in Texas (where I’m sitting at the moment), their options for accessing an abortion if they haven’t got many resources, money and social support, are really not that different.

Although you’ve got two very different legal situations – in the United States abortion is a legally-protected right, whereas in Northern Ireland it is not. But still women experiencing an unwanted pregnancy have strikingly similar options: you can either continue with that unwanted pregnancy, or you can travel a long way at high cost because with the closure of so many clinics and requirements for multiple appointments under new laws, you need to have the money and resources to actually get there and pay for the care. In Northern Ireland, you’re looking at a plane or ferry ride. In Texas, it’s at a very long drive – possibly hundreds of miles – or even a plane if you’re going out of state.

More recently, you’ve also got the options online. The biggest different is that in Northern Ireland there is Women on Web which is able to provide a genuine, safe, supported service to women. In the U.S. if your only option is to look online, it’s very unclear what you’re going to get. Online pharmacies may not be well-regulated – they are a bit of an unknown quantity.

In principle, you’ve got two very different legal situations, but the actual practical realities for women who don’t have many resources are very similar.

It’s surprising that in Northern Ireland, with the safety built into Women on Web, women may be in a better position to access a safe termination compared to women in the US.

I’ve often thought that myself. It was part of what motivated my paper that was recently published about the safety and effectiveness of online abortion using telemedicine, using Women on Web data. We know many women are doing their own abortions using pills online, and we want to know if it’s safe and effective. I was sitting in America thinking, “Gosh, women here do not have that option, and I would love to be able to understand what’s not available to them by virtue of not having that service.” If that service were available, could we say it would potentially be safe and effective? Could we say it is a public health imperative to be able to provide them with a service like that?

For people who aren’t familiar with Women on Web, how do they ensure that safety and efficacy we’ve been talking about. 

There are a number of ways in which they do that. Of course the service is still completely remote and online – you don’t someone face-to-face. You have a consultation with a doctor online, and medicine is prescribed to you by that doctor. What’s different about it is that you have to fill in your own online consultation form, which is entirely reliant on self-report. They trust women to say, “Here is my medical history and my gestational age, and this is an accurate report.”

One of the biggest worries people have about the service is that women might be at a more advanced gestational age than they say they are, and this could lead to problems. It was one of the things we were able to look at in the paper. We found that the service does have very high levels of efficacy, comparable to what you would see with the same medications in the clinic setting, as well as very low rates of complications. The first reason this might be so is that the instructions are very clear about how to take the medicine, what to look out for, and what the red flags are for serious complications. There is also advice about where do you go, what to do if complications do happen to you. Women on web also offer almost real-time support – you’re emailing back and forth with them before, during and after the abortion so that you’re able to get your questions answered.

Women are reassured the medications really are mifepristone and misoprostol in the correct doses, packaged in a way that’s stable, so they won’t degrade and becoming ineffective in transit.

These three things: clear instructions, genuine medications and a really good source of support with access to quick information when you need it, makes Women on Web different to just an online pharmacy.

Might online services be a preferable way to deliver terminations, even in a country like England where the NHS provides terminations in hospital?

This is something I hope to be able to describe in upcoming research in which we’ve been asking women about whether they would actually prefer this kind of model. It’s a very individual thing and a big challenge in abortion care in the future: how we can individualize care to suit the needs and requirements of every woman?

There are some women who are always going to want to go to a hospital – they just feel better about being in a medical setting and they get reassurance from that. There will also be people who are over a gestational limit and may need to go in for a surgical abortion. But for many women in Britain as well as Northern Ireland, there are many barriers to accessing clinical care that aren’t necessarily thought about. It may not be a financial issue if the procedure is covered by the NHS, but there are still issues of transport, distance, finding childcare or getting time off work. There are other women who want the independence of doing an abortion at home where they feel comfortable and in control. I often think about home birth in relation to this. There are some women who are low risk, and are just more comfortable out of a medicalized environment.

I think that telemedicine is the future of abortion care under a certain gestational age. The legal barriers in many places are still really high. It would take both a political change and a medical culture change to really allow that to take off as a model and realize its full potential.

**Part 3 of the interview will be posted later this week.**

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