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Preventing Pregnancy in Homeless Women

Duration:
43 minutes
First broadcast:
Thursday 02 August 2012

The number of people sleeping rough on Britain's streets is rising, and the need for supported housing continues. But providing a roof over someone's head is just the start.

A nurse specialist, working in day centres and hostels, provides health services to the homeless. It's an ideal opportunity to try to engage with clients, who usually fall under the radar of a general practitioner.

Physical health problems associated with living outside are common, and many suffer from mental health problems and drug addiction.

Women who find themselves on the streets are particularly vulnerable to assault, and sex work often provides a means of escaping the streets, and also funding a drug addiction.

The chaotic nature of these women's lives means they are often reluctant to accept the nurse's help. Getting these women to use regular contraception is a particular challenge.

Pregnancy is not uncommon among homeless women and their children often end up in care. Despite the terrible trauma this causes, women still find it difficult to use regular contraception.

What lengths should the sexual health team go to to encourage these women to avoid unwanted pregnancies?

Producer: Beth Eastwood.

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    Inside the Ethics Committee – Incentives - Blog
  • IEC - Preventing Pregnancy in Homeless Women - Transcript

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE THE ETHICS COMMITTEE

    TX DATE: 02.08.12 0900-0945

    PRESENTER: JOAN BAKEWELL

    PRODUCER: BETH EASTWOOD


    Bakewell
    How do we help the most vulnerable in society who simply aren't capable of helping themselves? Homeless women who are drug addicts often pay for their addiction through sex work, with all the risks of pregnancy and infection. Should the team who aim to help them offer them money to use contraception?

    Welcome to Inside the Ethics Committee.

    Amanda lives a chaotic life. In the spring she was living in a hostel for homeless women, we caught up with her in the garden there. Her story is typical of the women who find themselves homeless.

    Amanda
    I relapsed over 17 weeks ago and I got thrown out of the dry house that I was living in. So I was sofa surfing for a couple of weeks, staying at my sister's, staying at my dad's, staying at people's houses which weren't very good for me, kept using and then I had an interview for another place, I got into there, then I relapsed. I was kicked out of there and then I was sofa surfing again for a little while and then I got into this hostel what I'm in now.

    Nurse
    Amanda has been known to the homeless team as a whole for roughly about five years.

    Bakewell
    The nurse who specialises in the health of the homeless regularly visits the hostel.

    Nurse
    She's had periods when she was street homeless and having to sex work to survive and to feed a drug habit. And she goes through periods of stability when her addiction becomes more under control and she manages to develop insight into what she needs to do to make changes and then unfortunately it can only take a very small thing for something to happen and end up back down at the bottom again.

    Amanda
    The first time I was homeless I was living in my house with my kids, I started using, then I turned my house into a crack house, my kids got taken away from me. Then my house was - yeah my house was set on fire and then I moved out of there and I made myself intentionally homeless.

    Bakewell
    Such chaos is all too common, and addiction often lies at the root of it…

    Nurse
    Drug addiction has a huge impact for a lot of the women that we see in terms of their lives on a day to day basis as well as on their health. It often means that all they can think about is getting the next drugs, whether that's alcohol, crack cocaine or heroin.

    Bakewell
    Amanda grew up in the world of addiction, with tragic consequences for her children. She first smoked crack cocaine about a decade ago.

    Amanda
    I went to prison for importation and I met some girl that I was going out with, she left prison, she started to live with me and she was selling work and I'd follow her to go and sell the work up the West End and people's houses and stuff and I'd watch them and what they was doing and get a bit inquisitive. So I went home one day and tried to set it up myself, tried to make my own pipe and it basically started from there. My mum used, my dad used, it's been in the family. So it's been a cycle from there. My kids were taken away by social services and I never got them back and my kids are 18, 17, 16 and 14 and my son was six when he got taken away and he's 18 now. But they've never seen me use but they've been in the house while I've been using so obviously it is an unstable environment because I would buy them whatever they want just so that they could not bother me or I'd be in the bedroom for hours on end and only come out to give them something to eat or something like that and they'd see strange people coming to my house and you know - so it was chaotic.

    Nurse
    The women who find themselves homeless are obviously much more vulnerable in terms of being manipulated and being assaulted while they're on the streets. So they quite often get themselves out of being rough sleepers by sofa surfing or other means to make money, for example, prostitution.

    Amanda
    I got into sex working because I got caught too many times doing credit card fraud basically and I was just too scared so I started sex working. But I always thought that I was too nice for that, I was too embarrassed for anyone to see me standing out on the hill, so it was a thing like that.

    Bakewell
    The stability that the hostel provides is helping Amanda stay away from crack and sex work. Women living on the street often don't use the health services available in day centres so the hostel offers a chance for the nurse there to treat the women for conditions associated with living outside, chest infections for example.

    Nurse
    Another typical problem that a lot of these women have if they're smoking a lot of crack they're quite often will have skin problems, so they will pick anything that's broken down in terms of their skin and so they may develop large infected wounds. Again we can clean those up, dress them, give them antibiotics for them.

    Bakewell
    But the nurse struggles to reach them, even in the hostel.

    Nurse
    I will knock on all of the women's doors every time I'm there and more often than not the women are either not in the hostel because they're out drug seeking or getting funds to obtain their drugs or they're asleep because they've been working all night or they're on a come down because they haven't been able to get the drugs that they want and therefore their health is not a concern to them because all they can think about are the drugs. It can be disheartening when you know that their needs are not being met but on the occasions when you do have a small window of them wanting to engage, even if it's about a very small health matter, seeing them have that small increase in self-belief and self-worth is enough to make it all worthwhile.

    Bakewell
    Now it's time to hear from our panel of experts they are:

    Ann Skinner - Founding Director of Resolving Chaos, a non-profit social business sprung from the Department of Health and she also chairs Homeless Link.

    Deborah Bowman - Professor of Ethics and Law at St George's University London.
    Richard Ashcroft - Philosopher and Professor of Bioethics at Queen Mary University, London.
    Dr Tamsin Groom - Sexual health doctor who was among those who set up the homeless service at the Sandyford in Glasgow which is pioneering new ways of working with the vulnerable.

    Ann Skinner, first of all, what is the scale of the problem, it sounds as though it's specific and almost unreachable?

    Skinner
    I think for a lot of women with chaotic lifestyles the key issue is that they're living in fear and they're often in and out of the system but the system doesn't work for them. For example, a lot of women they don't get counted in rough sleep accounts that happen on the streets the first thing in the morning where women are not on the streets, they're often sofa surfing or the hidden homeless - sleeping on people's floors through fear of crime and attacks. They come and sleep on streets during the day.

    Bakewell
    How do you know how many women there are out there?

    Skinner
    We don't, the rough sleepers counts look at what sort of services would be needed to give help and support to those people on the streets but if they're not counted as part of the street count then they're not embedded within the services.

    Bakewell
    So they're almost outside society in some regard?

    Skinner
    Outside of existing services, outside of existing assessment.

    Bakewell
    Tamsin Groom it sounds as though Amanda's problems started very early if her parents both used and is that quite common?

    Groom
    In my experience it is quite common unfortunately. Social deprivation seems to pervade generations, particularly in Glasgow where I work.

    Bakewell
    So how do you come to encounter them?

    Groom
    We have a sexual health service for the homeless that we set up. Initially it was a group of doctors and nurses involved in that, unfortunately due to funding cuts we're down to one nurse who does an awful lot of outreach herself - visits all the hostels trying to find people. We have a vulnerable young women's project that deals specifically with girls that are at risk of prostitution, they're very good at bringing them in to see us.

    Bakewell
    Ann, do you feel that you can influence them once you have them within reach?

    Skinner
    I think that the biggest successes of some of the projects that we've worked with has been around peer advice and women who've actually been there and have come out of it. We use something called a consistent trusted adult model where somebody works with the individual, wherever they are, whether they're in a hostel or sofa surfing or whatever, so follows that individual, often a volunteer or a peer advocate who that woman will trust and continue to talk to along that woman's journey.

    Bakewell
    Deborah Bowman, do you think they really want to be reached?

    Bowman
    I think that that question pre-supposes all sorts of things that I'm not in a position to judge. It seems to me that duty of care in the context of the most vulnerable people probably has to be a little bit more imaginative and I think what Ann was saying for me really summed that up, that our traditional model of a doctor sitting with appointment times in a hospital simply isn't going to work. And there is an onus on professionals to think about that. And it's very easy to slip into - perhaps unwittingly - slightly pejorative language that the wayward, the deviants from the norm.

    Bakewell
    I use that vocabulary myself because in a sense we see them as outside the norms. Do we acknowledge our obligation to help them? Richard Ashcroft.

    Ashcroft
    I think we have an obligation but we don't acknowledge it. It's very easy to focus on some aspects of Amanda's story and the story of women like her - the sex work, the credit card fraud, the drug dealing - and yet it comes out in her story just how these things come about and how they're not exactly choices that she's made - I know I think I'll become a drug addict. And then there's little things that come out like when she says that somebody set fire to her house so she left it and became intentionally homeless, well there's a piece of language that comes from the state sector - you have left your home therefore you are intentionally homeless - and yet in no ordinary meaning of the term is she intentionally homeless, we have in a sense done that to her.

    Bakewell
    Okay let's go now back to the team that's trying to help the women in the hostel. It's likely that they all need help with their sexual health - pregnancy and sexually transmitted infections, known as STIs. The doctor who deals with such matters in the community.

    Doctor
    There is actually very little research data on what the sexual health needs of homeless people are. From the little bit of data that is available unmet contraceptive need comes high on the list, traditional STIs - chlamydia, gonorrhoea, syphilis - are all more common but we can't really make too much of the research evidence because it is not good.

    Bakewell
    Specialist sexual health clinics are available to these women out in the community, but they rarely attend. Many of them were abused in childhood, and raised in care: homeless women see themselves as outside the norms of society.

    Doctor
    Homeless people have the same right to access our health service as anyone else, we do not ask for identification. So theoretically homeless people can just walk into any of one of our drop in centres and get exactly the same care. In practice we don't see many homeless people, either because we don't recognise them as homeless or because they don't come and it is my hunch and the hunch of everyone else they don't come.

    Bakewell
    The nurse at the hostel.

    Nurse
    There have been specialised sexual health clinics set up to try and help these women access them, so open at certain times so that these women feel that they can go and not be judged. Unfortunately the impetus it takes to get yourself to a clinic and feel confident to discuss very intimate things with a complete stranger really doesn't fit for these women.

    Doctor
    Maybe because homeless people have generally poor experience with health services, if you are a homeless drug user and sex worker then you have three stigmatising conditions and they don't come.

    Bakewell
    Amanda readily admits that it's not easy to ask for help…

    Amanda
    I think what it is where some of our lifestyle is so chaotic, yeah, we find it hard to go and do things like that for ourselves, to go and have a check-up, to go and have a smear where it's so chaotic.

    Bakewell
    The nurse at the hostel does all she can to encourage women to use condoms but she can't actually prescribe other contraceptives there. Women have to go to one of the clinics in the community which, as we've heard, they rarely use. Even for Amanda, who is at a more stable point in her life, it's difficult.

    Nurse
    What's interesting is that someone like Amanda is actually doing really well and she's made huge steps into improving her own life and health but even for her the idea of going out and asking someone what options for contraception there are out there it's just still way down on the list of priorities.

    Amanda
    I always gave thought but sometimes you didn't really care, you know, because you just wanted to get your drugs and get back to somewhere safe where you can go and smoke it, you didn't think if you were safe out there having sex, you just wanted to get your money and get back to somewhere safe to smoke it. And it was only of recently where I found out that I caught an STI. While I was sofa surfing this time round me being homeless.

    Bakewell
    So such women are particularly likely to get pregnant, with all its tragic personal consequences

    Doctor
    When a person is homeless contraception is unlikely to be a priority for them and people use opiates or methadone, they become amenorrheic and expect not to see periods or often consider themselves infertile and contraception really doesn't get up on their priority list at all. They are of course not infertile and can still conceive and pregnancies occur and pregnancies are diagnosed late and pregnancy complications are relatively common. The likelihood that a child it will be taken away from the mother is very high and if the mother were to be homeless I would expect this to be approaching a hundred per cent.

    Nurse
    We do know of a woman who's got six children who've been taken away from her and another one who's got five and unfortunately that's not a rarity - lots of the women that we look after have three or four children who've been taken away from them and they still don't have contraceptive in place to prevent that from happening again even though they know that if they did become pregnant the likelihood of them keeping the baby is very, very slim.

    Bakewell
    The need for a specialist sexual health service right there at the hostel is clear. The nurse tells of a case that isn't untypical.

    Nurse
    There was one girl who the whole team know because she's been in and out of a lot of different hostels. She's got a prolific crack addiction that she's had since the age of about 14 and she came from family background of her mother being in sex work and also her being taken into care and being abused in care and her running away from care at a very young age. And she became pregnant and we discovered her pregnancy when she was already six months pregnant and that was because she was so underweight and she didn't have periods. As a team we felt she had an undiagnosed learning disability and that has since been confirmed. She really believed that if she went to her appointments that that was going to be enough for her to keep her baby and seeing how destroyed she was when that baby was first taken away from her really made us all feel like we really needed to be pulling out all the stops in terms of helping these women make choices, not stop them from having children but helping them decide to have their babies when they could get the opportunity to look after them.

    Bakewell
    Right well let's take up the issue again with our panel. Tamsin Groom, pulling out all the stops, she said, so what options do the team have?

    Groom
    When they haven't got a nurse that can prescribe and administer contraception then I suppose their options are fairly limited. They can take the woman, physically, to a service if they're willing to go.

    Bakewell
    But we've heard of really terrible cases - women having five children, six children taken away from them and how does a woman ever cope with that?

    Groom
    I don't know. Each time I think these people feel that it's going to be different next time - they've found a different partner, the partner's promised them that they'll look after them, this is quite a common thing, and yes they'll look after them quite nicely by helping them go out on the street and perhaps earn money for them to fund their own drug habit is the kind of stories that I hear time and time again.

    Bakewell
    Ann Skinner, contraception is available at pharmacies, it's around, so how is it that there is no one who can prescribe contraceptive in the hostel, don't you find that very odd?

    Skinner
    Actually I don't find it very odd because I think there's an awful lot of services that should join up that don't join up because professionals don't talk to each other. A lot of the sort of services that would help join up the services are the sort of voluntary sector peer support advocates who could actually go with the woman and talk to the doctor and talk to the hostel.

    Bakewell
    Richard, we're hearing about all the problems that all these different agencies have, first in joining up, but they're certainly all willing to help - can we interfere too much in people's lives?

    Ashcroft
    I think it is the case that we can interfere too much in people's lives. When I was talking earlier about how far Amanda is genuinely involuntarily homeless that's an example of where the system functioned rather well by its own lights to produce the result that it's designed to produce with bad consequences for Amanda. And that will be the case for many homeless women and men and the resistance they may feel towards formal professional help or even the voluntary sector, because I imagine from their point of view these things don't look all that different, is all too easy to understand.

    Bowman
    One of the things that strikes me is that we've heard these cycles of disadvantage and actually why on earth would you believe in a state support if your first experience has been care where you were bounced from place to place, where your social worker may have changed endlessly. You know it seems to me that actually the state rather than it interfering too much may not have done a very good job and it could be entirely rational to feel the disengagement from services, however well intentioned. It seems to me trust and dignity are at the heart of effective relationships here.

    Bakewell
    To what extent could it be said that these women have become addicted to the drugs so they've, in a sense, yielded their autonomy to the drug thus entitling society at large to interfere?

    Ashcroft
    There's a lot to that. I mean one way to think about some addictions is that they are just like mental illnesses and just like mental illnesses, under some circumstances, we intervene and we take over. Yet even modern mental health services try to work with their clients, rather than simply imposing solutions upon them partly for the reasons of trust and dignity that Deborah mentioned and partly out of pragmatism. If you want a solution to take, as it were, you have to work with the person in front of you. So it does make sense to think how someone who's addicted lost their autonomy but in practice it may not be that helpful in guiding how you work with them.

    Bakewell
    Tamsin, do you think the health service is realistic about what can be achieved?

    Groom
    I think a lot of our services have barriers, as we've already heard homeless people don't feel that they can come to the service, they don't meet the needs of the homeless and I suppose that's what we try to do with our outreach nurse and also we have fast track cards for vulnerable clients who can just bring and present a card to any of our service, they don't have to wait in a busy drop in.

    Bakewell
    What's the biggest barrier to achieving what you want with these chaotic women?

    Groom
    I mean there are challenges because sometimes it does feel like they don't wish to be helped, which is not true, they're just not at the right stage. I mean I've got a number of people that I've seen over the years, a very young girl, maybe 15 when we first got in contact with her, offered her all the sexual health screens, which she did, she was already selling sex at that point but she wasn't saying that she was doing that. Later on after a rape she eventually did say yes okay I'll have my coil inserted now because I don't want to get pregnant from that incident. But prior to that she didn't want any contraception because she felt that her boyfriend and her did want to have a baby and she couldn't quite see that that might not be the best thing.

    Bakewell
    Okay well let's go back to the story. The team at the hostel call on the sexual health team to provide contraception to these women on site. They meet up to talk through the options. The community sexual health doctor.

    Doctor
    It was a conventional meeting, we just talked to each other, bounced ideas around, tried to get an idea of the scale of the problem to see how we can best meet the needs of this population and then discuss potential options.

    Bakewell
    They discuss what type of contraception would be suitable. The sexual health nurse.

    Sexual Health Nurse
    This group of vulnerable women due to the fact that they're so chaotic maybe remembering to take a pill every morning will not be at the forefront of their mind and so within the meeting we discussed that the best contraception would be long acting reversible contraception, this is contraception that you do not have to think about on a day to day basis, they last anything from three months to five years depending on which one you opt to have and these are the injection, the implants or the coil. So it was about promoting a form of contraception that they really don't need to think about for a long period of time.

    Bakewell
    The team decide on the implant, which is inserted under the skin in the arm.

    Doctor
    Contraceptive implants is really an ideal technology for this - very safe, very easy to provide, works for three years, instantly reversible should a person wish it. It can be done in a single setting. It is more effective than any other method we have and extremely safe.

    Bakewell
    But while the implant will prevent pregnancy, the real challenge is getting the women to agree to it in the first place. The team discuss ways of engaging the women at the hostel.

    Doctor
    We discussed with the homeless team and because we have tried more the homeless team than us to engage with these women and to help them without much success I thought we may have to do differently, that is where we thought we need something to engage women so there was a suggestion that we invite them for lunch, there was a suggestion that we could give them a basket of cosmetics. And then it was my suggestion to give them money along the lines of I would really like to pay everyone who accepts an implant - £20 on the spot.

    Bakewell
    The doctor thinks a financial incentive might work for these women.

    Doctor
    For a person who has drug dependency often they don't think so much of future benefits and therefore if you don't value that type of concept very strongly having a family planning injection now to prevent something which you don't really value that much then why after talking to me should they change their mind? So I thought that if people value the immediate returns more than the later returns then we need to frontload it with immediate returns, in our case vouchers or money. That caused quite a round of jaw dropping. Everyone in that meeting apart from me felt that this was not a way to go on.

    Bakewell
    The nurse at the hostel.

    Nurse
    The basis of the work that we do with them is helping them learn to trust us, trust professionals and I felt that by offering them money it showed really that we didn't trust them to make the right decision.

    Bakewell
    The doctor explains how other incentives are already used to help people.

    Doctor
    Paying people to adopt a better health behaviour is not unusual, it is very, very fashionable at present. There are stop smoking projects which incentivise people, there are weight loss projects, that is used in drugs management where people receive vouchers or other rewards for staying off drugs and the evidence, particularly in the drug setting, for this is very good.

    Nurse
    I am aware of the use of incentives and they're used very effectively to help people complete a course of hepatitis B vaccination and that's because people will have to re-attend on several different occasions to complete the full course. But I think it changes when you're looking at using it for such an emotive subject as preventing pregnancy.

    Bakewell
    The team's leading principle must always be - as in all medicine - do no harm. They came together to discuss the issue.

    Doctor
    The harm from unmet contraceptive needs in this population is massive. To the person themself, to the child, at the very least it is very expensive to us as a community. So investing a bit upfront to avoid this harm seems like reasonable economy to me.

    Nurse
    There have been headlines in the press when vulnerable populations are offered incentives and so there is this fear that people would perceive what we were trying to do in a negative light, such as headlines about homeless women being paid not to have children.

    Bakewell
    The sexual health nurse is also reluctant.

    Sexual Health Nurse
    I personally felt uncomfortable. These women have got such low self-esteem anyway, they are so themselves any which way to get some money to feed their addictions. I felt by offering the £10 or however much it would be, we'd be feeding into that.

    Nurse
    And it added to that stigma of seeing them as a group that had to be bribed to do things to look after themselves whereas actually our experiences that if you treat them as individuals as you do other people you meet you soon find out the reasons why they do or don't do things and actually that's the key to helping them have informed decisions about their own health.

    Sexual Health Nurse
    Round the table there was a lot of debate - we're just offering them an incentive and putting in the implant. You're missing out the wider picture of sexual health and contraception. I felt like we needed to inform these women about all the types of contraception that is available to them, all the different types of STIs that they could be exposed to if they didn't use condoms properly. They wouldn't be thinking about the implant either and what it does, how it works, it would be more around getting the money so they can use that for whatever which way they felt.

    Doctor
    As all of this were not medical questions, they were ethical questions we could not decide in the circle whether this was a good idea or not. It was too reasonable to discount it but it wasn't straightforward either. We took it to our local ethics committee.

    Bakewell
    Well let's go back to our panel of experts to discuss the ethical issues. Let's take on board the case made by the doctor - that he's in favour of financial incentives for these women. Richard Ashcroft, you've been looking at the role of incentives in medicine.

    Ashcroft
    That's right, I am co-director of a research centre called the Centre for the Study of Incentives in Health funded by the Wellcome Trust.

    Bakewell
    So what do you make of this doctor's attitude?

    Ashcroft
    Well the first thing is to say that his thinking is entirely consistent with lots of other initiatives that are going on and I would say that I have a lot of sympathy with what he's arguing.

    Bakewell
    There have been other situations abroad even of people being bribed to undergo certain health treatments?

    Ashcroft
    Yes this is right and there are some fairly notorious examples of various kinds of schemes offering sterilisation or long acting contraception in various countries but several times in various states of India and we also know of a project called Project Prevention originating in California but now in various other sites in the United States and briefly it was attempted to get it going in Scotland, I believe, which again was offering drug addicted women money to get sterilised, which has attracted a huge amount of controversy. Well one of the questions about those schemes - well there's two. One is to do with social justice, which groups are being targeted and why are they being singled out? And the other question has to do with well whose interests are really being promoted? Quite often schemes of this type are promoted on frankly eugenic grounds, there's a belief that certain sorts of children shouldn't be borne, certain sorts of people shouldn't be having children. Whereas the case we're talking about here the scheme is so clearly motivated by wanting to act with the consent of the individual patient in her interests that I don't feel the same kind of eugenic inspiration lies behind it.

    Bakewell
    You've dropped the bomb into the conversation, which is the word eugenics, it says Nazi treatment of Jews, it's a terrifying word. Before we leave the doctor's point of view, Richard, does incentivising health work?

    Ashcroft
    There was a period of time about five years ago when the Department of Health and other agencies got very, very excited about incentives in all kinds of areas of public health. The unfortunate thing is most schemes are never properly evaluated, so we don't know whether they work or not and in some areas where they are properly evaluated the evidence suggests that they don't actually work. And we do know of one or two cases where incentive schemes do work - they do work rather well in treating crack addiction and heroin addiction and it has some benefit in helping people give up smoking as well.

    Bakewell
    Tamsin, what's your reaction to these options?

    Groom
    I feel very much with the nurses in the story really that there's nothing that's engendering any self-esteem by commodifying them further and for a medical professional to give somebody money I find that inherently wrong.

    Bakewell
    What about a box of cosmetics, was mentioned?

    Groom
    So they make themselves beautiful to go on the streets and pick up somebody else - I think not.

    Bakewell
    Ann Skinner, what do you think of this?

    Skinner
    Twenty pounds or whatever it was, £10, to me is not a huge amount of money, it doesn't feel like a bribe to me. They're already spending the money on drugs...

    Bakewell
    Well they might spend it on drugs, does that matter?

    Skinner
    They might well do but if it's got them into the surgery and they've got an implant and their health is more protected. And I think there's another angle in that if by providing a preventative service like this you're saving money to the public purse, I think it's their money, you would have spent it on them in a different way.

    Bakewell
    The team also considered having them round to lunch.

    Groom
    That is something that we've done in Glasgow in a similar sort of way I suppose. For instance we have a drop in centre for women involved in prostitution and yes there were sandwiches and shower facilities and washing machines and things like that, so I suppose you could argue that that's an incentive but not actually giving somebody money.

    Bakewell
    Richard?

    Ashcroft
    You see I think money's quite a good thing and I'd like more of it. I could say that one is persuading a woman to give up her facility for a plate of sandwiches, how is that better than giving up your facility for £20? At least £20 she can choose what she does with it. So there's something to be said for the money. Now there are lots of other considerations - you're only focusing on fertility, you're not focusing on sexually transmitted disease prevention, you're not focusing on the homelessness or the addiction and so on but if this is one small thing you can do and it makes a difference that's a little bit further down the track than we were when we started.

    Bowman
    I think one of the things that strikes me is that for all our well intentioned discussions of lunches and cosmetics one way to find out what might incentivise these women might be to ask them.

    Bakewell
    Well a lot of nodding going on round the table. So you are now the ethics committee and I want to know what you would recommend. Tamsin Groom first.

    Groom
    I'm not in favour of giving money because I don't think the money will go to that particular woman, I think it would go to her partner, her pimp and there'll be encouraging her to come back and get it out shortly afterwards so that she can then get another £20 in a few weeks' time when she has it re-put in.

    Bakewell
    Okay a no. Deborah Bowman.

    Bowman
    It's a no with a caveat that if it were part of a wider provision of services. I need to know more about what the incentive is linked to. However, at the moment I'm not persuaded it's a good idea.

    Bakewell
    Richard Ashcroft.

    Aschcroft
    I would say yes but two conditions. First, consult with women in this situation and see what they think of it and second, it has to be properly evaluated to see whether it works, whether it makes a difference.

    Bakewell
    And Ann Skinner.

    Skinner
    Completely agree with Richard, I think the caveat for me is the same as Deborah's, that it has to be part of a bigger support package, so it's not just an implant and bye bye.

    Bakewell
    Right, so that's the judgement of our ethics committee. What happened to the actual ethics committee when they met?

    Doctor
    The ethics team found this a fascinating case. They were almost evenly split but the majority felt that it should go down a conventional information, education, communication route but have a low threshold for coming back if this were not to be successful. There was a large minority in the ethics committee who felt that actually give it a go because there's not a lot to lose and if it works a lot is to be gained because the misery of just having to take one child away from their mother is such a massive misery that not trying our best to avoid this could be seen as unethical.

    Bakewell
    So the team adopted the initial plan - the sexual health nurse put on health promotion lunches at the hostel to encourage women to turn up, and then used this opportunity to go through the different options including their favoured option - the implant.

    Sexual Health Nurse
    It was about giving them the knowledge for them to make their own choices around what contraception they wanted. So by doing the health promotion events with the lunch, which is a sort of incentive because it brings them to the table, you can have discussions rather than just saying if you have an implant you get £10.

    Amanda
    They came, they put up the posters of gonorrhoea and what it looks like and things like that kind of frighten me now whereas I think before it wouldn't frighten me, I wouldn't go and have a check-up, I would just have something to smoke and just make that tell me that everything's alright, I would just forget about it. So things that are good.

    Sexual Health Nurse
    We made it very informal, we all sat around the table and the women came down and we sat and had lunch with them.

    Amanda
    And they came with all these different condoms and showing us how to put condoms on because sometimes we don't actually know how to put a condom on. So I think that one was really helpful.

    Sexual Health Nurse
    We were also asking them what their knowledge is around contraception and it was quite interesting that actually it was quite poor. All they really knew was pills and injection, they didn't know about the coils, the implants etc.

    Amanda
    What else was there? Women's condoms, yes, that was the one that got me because I've never seen that one. And we got to see the women's implants, she showed it to us in a little box, it's like a little matchstick.

    Bakewell
    Amanda, whose life is relatively stable at the moment made the decision for herself.

    Sexual Health Nurse
    To me that was a sign straightaway that she was at that point that she didn't - she could change in relation to her contraceptive choices. However, she was finding it difficult at times to remember, so I spoke to her about the implant and she didn't really know about it. So we sat in detail, talked about it.

    Amanda
    So she told us about how they put it in and it doesn't really hurt and stuff like that and made us feel comfortable and safe.

    Bakewell
    Amanda decided to have the implant.

    Amanda
    They gave me an injection first to numb the area, then they inserted the implant in my arm. You can just feel the implant just slightly at the top of my skin. This one is every three years and I like the sound of that. It can't protect me from diseases but it's more safer for me because I used to get the injection, I'm supposed to get it every 12 weeks, so I wouldn't remember when I'm going to get the injection. At least with the implant I know that it gets changed every three years, I don't even have to remember that it's in my arm and it's a good guarantee that I am not going to get pregnant. I like the percentage of it and I feel safe with that.

    Bakewell
    Half of the 17 women at the hostel attended at least one lunch. Two have had implants. One chose a coil. So was the scheme a success? The sexual health nurse.

    Sexual Health Nurse
    I think that's actually quite a good success to be honest, considering when you think about these women who are using nothing and the fact that they have made the choice themselves to actually want the implant means that they will stick with it because they've made their own choice themselves, I feel if you forced it upon them by the incentive they could have gone and got it removed the following week. But actually we've also got to look about the seeds that we may have laid with those women that did attend the lunch, they may not be ready at that point to make the choice of having the implant but the next visit they may do. So when you say has it been successful - we've had two implants, so to me that's a success, one would have been a success.

    Bakewell
    And Amanda - should women like her be paid?

    Amanda
    I don't really think that's an incentive to do that to be quite honest. I think what it is where some of our lifestyle is so chaotic, yeah, we find it hard to go and do things like that for ourselves, to go and have an implant, to go and have a check-up, to go and have a smear where it's so chaotic. But you see like where I'm living now we've got all that here under our roof, so there's kind of no excuse for that really, so it's nice that we can have people that come here and tell us about stuff like that and they do it here in the house you know.

    Bakewell
    The sexual health doctor has his reservations.

    Doctor
    I think that two people taking up [indistinct words] set of contraception is a good outcome, whether it has been the most effective method is a different story. The response at lunches translating themselves into two contraceptive implants is not a lot. Personally I believe that had we invested our time and money into direct incentives that would have resulted in more benefit with the population, less harm, less costs to the health service and on balance I think that incentivising would have been a more effective and more ethical option.

    Bakewell
    The nurse who cares for the homeless women at the hostel who was initially reluctant about incentives now feels ambivalent about ruling them out entirely. The ethical dilemma goes on.

    Nurse
    Even though I feel that we have made a really good start I do feel that there are still women, like the one that I mentioned who made us all really want to do something more in terms of contraceptives, who we're still not reaching, she's still prolifically crack using, she's still hardly ever in the hostel and is still really lacking trust in meeting with anybody unless there's a monetary value to it. And my worry is that she's going to end up pregnant again and go through that soul destroying cycle and that's why I think we really need to take it back to the ethics board to discuss whether we're doing enough to help them and whether we need to reopen the discussion about incentives for those women who don't have any trust, so we're not breaking anything by offering them it.

    ENDS

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