Pause: Dundee project's 'rules on women's autonomy should make Scotland uneasy'

CRITICS of a controversial project which works with vulnerable mothers in Dundee have called for programme rules – insisting women who want ongoing support from the programme prevent pregnancy by either taking contraception or abstaining from sex – to be dropped.

They claim the Pause project, which Dundee City Council last year agreed to fund until 2023, set “a precedent on bodily autonomy” which should make Scotland “uneasy”.

Some campaigners say the same positive results could be achieved for vulnerable women who have had children taken into care without conditions being imposed.

The Pause project – an 18-month programme which supports women who have had one or more children taken into care – addresses issues such as mental health and addiction, and was piloted in the city in 2019.

Dundee is the only Scottish city to adopt the UK-wide franchised programme, run locally by Tayside Council On Alcohol. It was re-funded by Dundee City Council last September until the end of 2023 following an evaluation, which noted positive outcomes for women in terms of health and wellbeing.

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But though some have claimed the project offers women a “lifeline”, The Ferret has also learned that in August 2020, an NHS consultant raised concerns that women were “distressed” at appointments to have contraceptive devices fitted, leading to a change in criteria.

As a result of these concerns, it was clarified that women no longer need to use the recommended long-acting reversible contraception (LARC) – such as the coil or implant – with other contraceptive options accepted. Yet if they want access to the full programme of support, they must still agree to use some form of contraception after a four-month period or abstain from sex with men.

Women in the programme are often struggling with grief and trauma. The Ferret has previously reported on the connection between the drug deaths of women and those who have had children taken into care. This has been documented by a small sample of data gathered across the UK by the Pause project.

Project co-ordinators say the programme provides a “pause” from pregnancy to allow women space “to reflect and make changes” that will improve their life outcomes.

The project also aims to save millions by preventing pregnancies which could result in infants being placed in local authority care. In 2022-23, Dundee Council will provide £240,000 in funding. Pause claims it can prevent six to 10 pregnancies in the course of its 18-month duration.

But critics claim the same good outcomes could be achieved without imposing contraception or abstinence on the women and said the continued insistence on these conditions remained “ethically concerning”.

Pause board minutes released to The Ferret reveal a possible 103 women were initially identified as eligible in 2019.

Twenty-two women agreed to sign up – though one died suddenly. Another 16 did not go ahead with the full programme. A further 65, identified as eligible, could not be

contacted or did not want to be involved.

Minutes from August 2020 show that concerns about conditionality had been raised. They read: “(NHS rep) stated that she is aware of nine Pause women who had attended the clinic at Ninewells, with six not returning for follow up appointments and three going on to receive a service.

“She raised a concern regarding the conditionality of LARC [within the programme]. Specifically, she cited a woman she met who had been upset about having her LARC fitted, and although the woman confirmed it was her wish to have this, she appeared distressed.

“[She] and her colleague considered halting the appointment. The woman clarified she wished to proceed, but stated that she needed the service and support offered by Pause Dundee.”

The “NHS representative” quoted in the minutes – Dr Heike Gleser, sexual and reproductive health consultant for NHS Tayside – told The Ferret that her concerns were “historic” and that she had accepted amendments to the conditions put in place following meetings as an “acceptable compromise”.

But Dr Alison Scott, an Edinburgh-based consultant gynaecologist working with socially excluded women and former chair of the Faculty of Sexual and Reproductive Healthcare (Scotland), said support for women should not be conditional.

She added: “Women who have been traumatised and exploited deserve choice and autonomy of decision in their lives, including contraception.”

In July 2019, 16 experts wrote a joint letter claiming that offering support conditionally on the choices they made about their reproductive health could exacerbate issues with their “mistrust of official institutions”.

“As researchers, practitioners, and advocates, we agree wholeheartedly that better support for this group of women should be a priority,” they wrote. “We also recognise that long-acting reversible contraception can be enormously valuable in helping women take control of their reproductive choices. However, restricting access to the former based on the latter is ethically concerning.”

Many of the letter’s signatories said they maintained concerns about conditionality.

Justina Murray, chief executive of Scottish Families Affected By Alcohol And Drugs, said: “Support for vulnerable and at-risk women should never be conditional.

“We are tripping over policy and strategy documents which talk about ‘no wrong door’, and families harmed by substance use having the right to holistic, trauma-informed and person-centred support, and yet in practice in Dundee, we can see these ‘rights’ are very much conditional on women agreeing to pause their family life

altogether.”

Others had a more nuanced view. David Liddell, chief executive of the Scottish Drugs Forum, said that while his organisation continued to oppose “on principle” a service “that makes access conditional on a woman’s choices about her own body”, it did seem to be providing an “excellent service” for those who agreed to follow its criteria.

He added: “Our view is that the project could work equally well if there were no such conditions attached to women attending. The project would be adequately resourced to work with all women and to build empowering, trusting and therapeutic relationships with them so that women could freely choose to use long-term contraception without pressure or conditionality.”

Others working with women in the city agreed it had many benefits. The impact report, published in September 2021, showed that women felt more positive, with some regaining contact with their children, or starting work, volunteering or education.

Rachel Macdonald, service lead at Alternatives Dundee, a counselling service for those affected by abortion, miscarriage, infertility or child loss, said: “We have worked with women who have been referred to us by Pause, and for some of those women the support offered has been a lifeline and the team on the ground are amazing.”

She claimed that women in the Pause programme have been able to access counselling through the support of a worker, which they otherwise could not have done.

“Some women who have had children taken into care need therapeutic care,” she added. “They need and deserve that help and many of them have done so for many years.” In March, The Ferret reported on the issues facing women who had lost children due to substance misuse and mental health issues in the city. The women interviewed said that if they had got the support they needed, their children may not have been taken into care.

Labour MSP Monica Lennon (above) said Scotland should feel “uneasy” about the “precedent the Pause project was setting”, particularly at a time when abortion rights in the United States were being restricted and protests at Scottish abortion clinics were increasing.

She added: “It remains disturbing that services aimed at vulnerable women are making demands on their bodily autonomy. This sort of pressure, even when it is subtle, is not acceptable.

“At a time when sexual health and reproductive services are under pressure, with many women facing long delays to have coils removed, it’s important that all women can make the decisions that are right for them.”

A spokesperson for Dundee City Council stressed that the programme “forms part of a continuum of support for vulnerable women with a focus on those who have so far been unable to engage, or had limited engagement, with other services and are at risk of the further removal of

children from their care”. Other services in Dundee were available to support parents to care for their children “within birth families where possible” they claimed, with children removed only in “exceptional circumstances”.

They added: “The programme places a strong emphasis on informed voluntary engagement and person-centred support, alongside the woman taking a pause from pregnancy to help bring greater stability to their lives.

“During an initial engagement period of up to four months, women are provided with general support to meet their personal needs, including support to access other services. Where the woman considers this is sufficient for them, or if they do not wish to progress to the full Pause programme, each woman is supported to continue to engage with these other services.”

A spokeswoman from the Pause project said: “When women choose to join the programme, they commit to a pause in pregnancy. How women facilitate that pause is for them to decide with a sexual health professional.

“This is an individual decision and can look different for different women. We respect the women’s right to confidentiality and would not discuss individual cases as they may be identifiable – particularly in small communities of women.”

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