Dundee City Council recently announced plans to introduce “Pause”: a programme of intensive support for women with complex needs (such as substance use, mental health problems, or domestic violence) whose children have been, or may be, removed from their care. Continued support is conditional on their use of long-acting reversible contraception.
As researchers, practitioners, and advocates, we agree wholeheartedly that better support for this group of women should be a priority. 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.
Support for problems with substance use and mental health is an integral part of the human right to health, as is the right to self-determination in reproductive and sexual health. Given the known shortcomings of existing service provision for these issues in Scotland, does the offer of a much better level of care – with strings attached – truly represent a free choice? This form of targeted conditionality for vulnerable populations seems at odds with the current focus on human rights across Scottish Government strategies on substance use, mental health, and social security.
The women targeted by this initiative often have histories of complex trauma and coercive relationships, which themselves can be the drivers of repeated pregnancy. As a result, they can have difficulties establishing therapeutic relationships and a mistrust of official institutions. Offering badly-needed services contingent on reproductive control may only exacerbate these issues.
There is already extensive evidence on what works for women with these needs: gender-sensitive and trauma-informed approaches which prioritise trusting, non-judgemental relationships; continuity of support; and safety, empowerment, and collaboration. Pause – where support is conditional, choices are constrained, and women who become pregnant during the programme are “transitioned out” – does not appear to meet these criteria.
Dr Emily Tweed, Clinical Lecturer in Public Health, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow; Dave Liddell, Chief Executive Officer, Scottish Drugs Forum Justina Murray, Chief Executive Officer, Scottish Families Affected by Alcohol and Drugs; Jardine Simpson, Chief Executive Officer, Scottish Recovery Consortium; Emma Crawshaw, Chief Executive Officer, Crew 2000; Dr Malcolm Bruce, Chair of Board of Directors, Crew 2000; Joyce Nicholson, co-convenor of Praxxis Women; Adrienne Hannah, co-convenor of Praxxis Women; Dr Tessa Parkes, Director, Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling; Dr Maria Fotopoulou, Lecturer in Criminology, University of Stirling; Dr Hannah Carver, Lecturer in Substance Use, University of Stirling, John Burns, PhD researcher, University of Stirling; Rowdy Yates, President of European Federation of Therapeutic Communities; Professor Betsy Thom, Professor of Health Policy, Co-Director Drug and Alcohol Research Centre, Middlesex University; Dr Aileen O’Gorman, Programme Leader, Contemporary Drug & Alcohol Studies, University of the West of Scotland; Dr Andrew McAuley, Senior Research Fellow, Glasgow Caledonian University.