Select Committee on Science and Technology Written Evidence


Memorandum 9

Submission from Family Planning Association

EXECUTIVE SUMMARY

  i.  There have been no significant scientific or medical developments that would lead to the reduction of the legal time limit for abortion from 24 weeks.

  ii.  Although some babies born between 22 and 24 weeks' gestation have survived, the number of cases is very small and these babies often have significant disabilities. This cannot be seen as providing evidence of viability.

  iii.  The Dutch Pediatric Society and the Dutch Society of Obstetrics and Gynaecology have developed guidance on management of pre-term delivery, which defines 24 weeks as the limit of viability.

  iv.  The development of 4D ultrasound images of fetuses has not provided any new evidence which requires a reduction in the time limit for abortion. Fetal organ development remains the significant factor in determining viability.

  v.  Complications associated with induced abortions are rare. Research clearly shows that having a legal abortion is safer than continuing with a pregnancy.

  vi.  The current legal requirement for two doctors' signatures is placing an unnecessary burden on the NHS and delaying women's access to abortion services.

  vii.  Nurses, midwives and other trained healthcare professionals already carry out abortions in other countries. The evidence shows that it is a healthcare professional's level of training and experience that should determine their suitability to perform abortions.

  viii.  It is current practice in America that the second stage of a medical abortion is self-administered by the woman in her own home. Research has shown that home-self administration of misoprostol is safe, effective and acceptable.

  ix.  Reviews of the existing literature have found little evidence of adverse long-term outcomes from abortion. There is no conclusive evidence linking having an abortion to subsequent mental ill health. Evidence suggests that a significant number of women continue to suffer adverse effects after being denied an abortion.

  (1)  The scientific and medical evidence relating to the 24-week upper time limit on most legal abortions, including:

    (a)  developments, both in the UK and internationally since 1990, in medical interventions and examination techniques that may inform definitions of fetal viability and

    (b)  whether a scientific or medical definition of serious abnormality is required or desirable in respect of abortion allowed beyond 24 weeks.

  1.1  There have been no significant scientific or medical developments that would lead to a reduction of the legal time limit for abortion. Although some babies born between 22 and 24 weeks' gestation have survived, the number of cases is very small and these babies often have significant disabilities. This cannot be seen as providing evidence of viability.

  1.2  Based on the evidence of low survival rates and high rates of disability for babies born at less than 26 weeks, the Dutch Pediatric Society and the Dutch Society of Obstetrics and Gynaecology developed guidance on management of pre-term delivery, which defines 24 weeks as the limit of viability.[37]

  1.3  Before 24 weeks, the guidance specifies there should be no pre-term transport of pregnant women to level 3 perinatal centres; no antenatal steroid treatment; caesarean section on maternal indication only and limited neonatal care aimed at comfort of the infant and family.

  1.4  The review article detailing the Dutch guidance stated that `Further lowering of the limit of viability [below 24 weeks] seems possible only through a fundamental innovation of treatment of these infants whose organs have not matured sufficiently'.[38]

  1.5  In the EPICure study of babies born before 26 weeks' gestation in the UK and the Republic of Ireland in 1995, survival rates at discharge were 0% for those born at 21 weeks, 1% at 22 weeks and 11% at 23 weeks.

  1.6  The research showed that at 23 weeks' gestation only 12% of those who survived to discharge had no impairment, while a quarter had severe disability and 38% had moderate disability. At 22 weeks, only two babies survived to discharge and both had disability at age six. [39][40] [41]

  1.7  The Nuffield Council on Bioethics report, Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues, noted that prematurity is still a major cause of neonatal death in the UK and the prospects of survival for babies born up to and including 25 weeks and six days is generally lower than 50%.[42]

  1.8  The report considered evidence on survival and disability rates of pre-term babies and stated that the results to date were too limited "for the Working Party to conclude that disability in children surviving at the borderline of viability has improved".[43]

  1.9  The development of 4D ultrasound images of fetuses, pioneered in 2003 by Professor Stuart Campbell, has not provided any new evidence which requires a reduction in the time limit for legal abortions.

  1.10  Fetal organ development remains the significant factor in determining viability. Responding to Professor Campbell's 4D images, Dr Huseyin Mehmet, Reader in Developmental Neurobiology at Imperial College, London stated that "Scans that look at the structure of the fetal brain at 23 and 24 weeks show that the human brain is extremely immature. It is the period between 24 and 40 weeks that is largely responsible for brain development".[44]

  1.11  A recent article by Dr Stuart Derbyshire states that there is clear evidence that the biological system within the brain necessary for pain responses is not intact until 26 weeks' gestation and that at this stage much development is still required.[45] Research on fetal pain in America suggested that the brain was not sufficiently developed for pain perception before 29-30 weeks.[46]

  1.12  Lung development is another important factor. Although fetal breathing movements can begin at 10 weeks' gestation, they tend to be erratic and occur only 30-40% of the time until around 30 weeks. It is not until 30-32 weeks that the lungs make surfactant, which is necessary to keep the lungs' air sacs open.[47]

  1.13  There have not been developments in technology which significantly change the time at which fetal anomalies can be detected. The vermis of the cerebellum, a marker of brain development, is present at 15 weeks in 54% of fetuses, but is not present in all cases until around 19 weeks. This means that earlier scanning for anomalies is not possible, because a significant percentage of scans before 20 weeks would falsely identify an anomaly.[48] We are aware that it can be difficult to obtain an abortion because of a severe fetal abnormality after the current 24 week time limit. Lowering the time limit to a point before scans for fetal anomalies could be verified would cause significant delay and distress to a larger number of women who are already in a difficult situation.

  1.14  fpa does not believe that a scientific or medical definition of serious abnormality is required or desirable for abortions beyond 24 weeks. Clinicians must be able to exercise their professional judgment on a case by case basis.

  (2)  medical, scientific or social research relevant to the impact of suggested law reforms to first trimester abortions, such as:

 (a)   the relative risks of early abortion versus pregnancy and delivery

  2.1  Induced abortion is one of the most commonly performed gynaecological procedures in Great Britain. Guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) states that "abortion is safer than continuing a pregnancy to term" and "the absolute risk of complications at the time of abortion is low". The guidance notes that increasing gestational age is associated with an increasing relative risk of complications of abortion.[49]

  2.2  Analysis conducted in America into the safety of medical abortion found that the estimated case-fatality rate for medical abortion was 0.8 deaths per 100,000 procedures. This risk was statistically indistinguishable from the risk of death from miscarriage, which was 0.7 per 100,000 miscarriages. Both of these figures were much lower than that associated with childbirth. In 1997, the pregnancy related mortality ratio in America was 12.9 deaths per 100,000 live births.[50]

  2.3  The Sixth Report of the Confidential Enquiry into Maternal and Child Health (CEMACH) in the UK identified three deaths in early pregnancy that were connected to abortion during the period of the report. This compared to eleven deaths in early pregnancy connected to ectopic pregnancies.

  2.4  The Report noted there had been problems with the provision of abortion services, which could have contributed to the deaths. The Report documented the case of a woman referred to a centre without access to adequate emergency care. In another case, the results of routine swabs were not passed to clinicians who could have administered prophylactic treatment to prevent an infection, which subsequently caused a woman's death.[51] Since 2004, the administration of prophylactic antibiotics has been standard practice, in line with RCOG guidance.[52]

  2.5  Complications associated with induced abortion are rare. The risk of haemorrhage at the time of abortion is low, affecting around one in 1000 abortions. The risk of haemorrhage is even lower for early abortions: 0.88 per 1000 at less than 13 weeks.[53]

  2.6  There is a small risk with all methods of first trimester abortion of failure to terminate the pregnancy. The risk of failure to terminate with surgical abortion is around 2.3 per 1000 and for medical abortion is between 1 and 14 per 1000, depending on the drug regimen used and the experience of the centre.[54]

  2.7  Infection is the main complication associated with abortion, which is usually caused by a pre-existing infection. Infective complications occur in around 10% of cases. In line with RCOG guidance, the administration of prophylactic antibiotics is standard practice. [55]

  2.8  The RCOG describes the risk of uterine perforation at the time of surgical abortion as moderate at 1-4 per 1000. The risk is lower for abortions performed earlier in pregnancy. Similarly the risk of damage to the external cervical os at the time of surgical abortion is described as moderate (no greater than one in 1000) and the risk is lower when the abortion is performed earlier in pregnancy.[56]

  2.9  There is clear evidence that having a legal abortion is safer than continuing with a pregnancy.

 (b)   The role played by the requirement for two doctors' signatures

  2.10  An abortion is always safer than carrying a pregnancy to term. Therefore the current legal requirement for two doctors' signatures is placing an unnecessary burden on the NHS and delaying women's access to abortion services. Polls of general practitioners have shown that 18-24% describe themselves as broadly anti-abortion and do not refer women.[57] [58]

  2.11  There is anecdotal evidence that some healthcare professionals who refuse to refer women for abortions also do not refer them to a colleague who will help, despite professional guidance requiring them to do so. In 2005, research with women undergoing abortion between 19 and 24 weeks' gestation found that being refused a referral by a doctor was a major problem for some women and there were many examples of women being delayed through the referral process. The research reported that being refused a referral had a significant impact on women. Many of the women were shocked and some became upset when they recounted their experiences. [59]

  2.12  Further research has confirmed that delays in referrals could lead to women having later abortions. [60]Seven per cent of the women who had waited more than two weeks between requesting and obtaining an abortion, reported that the first person they had approached had made it difficult for them to get further appointments. The median waiting time for these women was 21 days. Four per cent of respondents said that the first person they asked about an abortion said it was not possible for them to have one. These women waited an average of 14 days. A further 4% said the first person they approached had told them they were opposed to abortion; the median waiting time for these women was 19 days.

  2.13  The research noted that women having later abortions who had waited more than 14 days between asking for and obtaining an abortion were more likely to have requested an abortion before 12 weeks' gestation. This suggests that in some cases the requirement for two doctors' signatures significantly delays women's access and leads to women having later abortions.

 (c)   The practicalities and safety of allowing nurses or midwives to carry out abortions or of allowing the second stage of early medical abortions to be carried out at the patient's home

  2.14  Nurses, midwives and other trained healthcare professionals already carry out abortions in other countries. In several states in America nurse practitioners, physician assistants and nurse-midwives are involved at various levels of abortion services.

  2.15  Research in Vermont and New Hampshire compared complication rates after surgical abortions performed by physician assistants with those for surgical abortions performed by physicians. The research showed that surgical abortion services provided by experienced physician assistants were comparable in safety and efficacy to those provided by physicians. For physician assistant performed abortions, the complication rate was 22.0 per 1000 compared to 23.3 per 1000 for physician performed abortions, which is not a statistical difference.[61]

  2.16  Similar research conducted in South Africa and Vietnam in clinics run by Marie Stopes International compared the complication rates for induced abortions before 12 weeks' gestation carried out either by a doctor or by a qualified "mid-level provider".[62] In South Africa and Vietnam, mid-level providers undergo standardised, government-accredited training in abortion. The research found that, with appropriate training, mid-level providers could perform early abortions as safely as doctors. In South Africa, the complication rate for mid-level providers was 1.4 per 100 patients and 0 per 100 for doctors. In Vietnam, the rates of complications were 1.2 per 100 for both mid-level providers and doctors.

  2.17  Research shows that it is a healthcare professional's training and experience that should determine their suitability to perform abortions.

  2.18  There is clear evidence of the safety, efficacy and acceptability of women having the second stage of medical abortions at home. In America, it is standard clinical practice to give women the second stage to take at home. Since mifepristone was licensed there, approximately 750,000 women have used it.[63] Research has shown high rates of success, with more than 90% of women having complete abortions, and high levels of satisfaction for women self-administering the second stage of their abortion at home.[64] [65]

  2.19  Research suggests home self-administration of misoprostol is feasible and effective in Great Britain. Research conducted in four gynaecology units in England and Scotland found that 71% of women said there was nothing that had happened during their medical abortion in the hospital that they could not have coped with at home.[66] In a study at Aberdeen Royal Infirmary, 49 women were provided with misoprostol to take at home: 98% of them were satisfied with having the abortion at home.[67]

  2.20  Similar results have been found elsewhere. Research in Sweden and France with 124 women who self-administered the second stage of a medical abortion at home also found that 98% of women were satisfied with the process.[68]

  2.21  In addition, during a series of interviews about the experience of having the second stage of a medical abortion at home in America, women described the process as "natural" and "private".[69] There is no reason why women should not be able to have the second stage of a medical abortion at home if they choose to do so.

  (3)  Evidence of long-term or acute adverse health outcomes from abortion or from the restriction of access to abortion

  3.1  Restricting access to abortion has a significant detrimental impact on women's health. It is estimated that 68,000 women worldwide die each year due to complications of unsafe abortion.[70]

  3.2  In Romania, policies restricting access to abortion led to a significant increase in maternal mortality from 20 maternal deaths per 100,000 live births in 1966 to over 100 per 100,000 in 1974 and to 150 per 100,000 in 1983.[71] After the restrictive laws were revoked, the rate of maternal deaths fell rapidly to 40 per 100,000 live births in 1989. It is estimated that around 200,000 Romanian women died between 1966 and 1988 as a result of unsafe abortion.[72]

  3.3  The CEMACH Report in 2004 included a commentary on previous reports of deaths caused by illegal abortion. The Report for 1952-54 included 153 deaths due to "abortion", at least 108 of which were illegal. Reports of around 30 deaths per year from illegal abortion continued throughout the 1950s and 1960s. During 1969, the first full year that the 1967 Abortion Act was in force, the number of deaths "clearly due to illegal abortion" fell to 17. The number of deaths due to illegal abortion could have been underestimated because the number of deaths attributed to spontaneous miscarriage also decreased from 1970, in parallel with those attributed to illegal abortion.[73]

  3.4  More recently, access to legal abortion in Nepal appears to have helped to reduce the maternal death rate. In 2001, the official maternal mortality rate for Nepal was 539 maternal deaths per 100,000 live births. Access to abortion was legalised in 2002 and a programme introduced to make safe abortion more widely available. In 2006, the maternal mortality rate in Nepal was 281 per 100,000 live births, a reduction of 48 per cent.[74]

  3.5  In 2004, a worldwide review of epidemiological evidence on breast cancer and abortion concluded that induced abortion did not increase a woman's risk of developing breast cancer.[75] The review also found that there was no significant difference in the relative risk of breast cancer related to the number of abortions a woman had, the woman's age at abortion or the time since the abortion.

  3.6  There is no evidence linking induced abortion to subsequent infertility in countries where abortion is legal. The RCOG guidance states that "published studies strongly suggest that infertility is not a consequence of uncomplicated induced abortion".[76]

  3.7  A review of evidence of long-term consequences of induced abortion published in 2002 found no link between abortion and subsequent miscarriages or ectopic pregnancies.[77] The evidence reviewed appeared to show an association between surgical abortion and placenta praevia. However, more recent evidence reviewed by the RCOG suggested that there was no such association with vacuum aspiration and that the previous links could have been due to sharp curettage techniques used to perform later surgical abortions.[78]

  3.8  There seems to be some evidence suggesting a link between induced abortion and subsequent pre-term births. The same review found an association between abortion and pre-term birth and suggested the elevation in risk ratio was between 1.3 and 2.0. The review also suggested that the risk of pre-term birth increased with the number of abortions a woman had had.[79]

  3.9  Much of the recent research that has appeared to demonstrate a link between abortion and mental health problems has significant flaws. For example, it does not address whether women who have had an abortion experience more adverse outcomes than women who have had to carry an unwanted pregnancy to term. Similarly, studies often do not take account of existing conditions. [80]

  3.10  Research by Professor David Fergusson appeared to suggest a link between abortion in young women and subsequent anxiety, depression, suicidal behaviours and substance misuse. However, this study did not take into account important factors such as pre-existing health problems. In addition, the researchers estimated that around one fifth of the women in the study who had had an abortion did not disclose it, which would have altered the results. [81]

  3.11  A review of the literature on the psychological sequelae of abortion and denied abortion, published in 1991, concluded that a minority of women experience an adverse psychological reaction after an abortion. However, these symptoms were often a continuation of previous conditions and many of them disappeared after the abortion. [82]

  3.12  The review suggested women who experienced more distress after an abortion were more likely to have low self-esteem, a higher sense of alienation and poorer knowledge of contraception. An abortion being medically or genetically indicated and a previous history of mental ill health were also risk factors. In contrast, adolescents who felt they had made their own decision about the abortion, without any outside pressure, were less likely to experience negative reactions.

  3.13  The limited research on the impact of denied abortion was also reviewed, which highlighted, as an area for concern, the high number of "spontaneous abortions" recorded in women who had been denied an induced abortion.

  3.14  Those women who carried an unwanted pregnancy to term after being denied an abortion appeared to have greater feelings of guilt and anxiety than women who had been able to access an abortion. Although an unwanted pregnancy did not always result in an unwanted child, a significant number of women (34% in one study) continued to report negative feelings such as resentment towards their children. [83]

  3.15  There is no conclusive evidence linking having an abortion to subsequent mental ill health. Evidence suggests that a significant number of women continue to suffer adverse effects after being denied an abortion.

August 2007







37   Verloove-Vanhorick S, "Management of the neonate at the limits of viability: the Dutch viewpoint", BJOG, vol 113 (Suppl 3) (2006), 13-16 Back

38   Ibid Back

39   Costeloe K et al, "The EPIcure study: outcomes to discharge from hospital for infants born at the threshold of viability", Pediatrics, vol 106, no 4 (2000), 659-671 Back

40   British Medical Association, Abortion Time Limits: A Briefing Paper from the BMA (London: BMA, 2005) Back

41   Nuffield Council on Bioethics, Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues (London: Nuffield Council on Bioethics, 2006) Back

42   Ibid Back

43   Ibid Back

44   Comments reported in: Henderson M, "New fetal scans `clouded debate on abortion'", The Times, 3 October 2006, <http://www.timesonline.co.uk/tol/news/uk/health/article658385.ece>, accessed 6 August 2007. Back

45   Derbyshire S, "Can fetuses feel pain?", BMJ, vol 332, 15 April (2006), 909-912 Back

46   Lee S J et al, "Fetal pain: a systematic multidisciplinary review of the evidence", Journal of the American Medical Association, vol 294, no 8 (2005), 947-954 Back

47   Institute of Medicine, Preterm Birth: Causes, Consequences and Prevention (Washington DC: National Academies Press, 2006), http://books.nap.edu/openbook.php?isbn=030910159X, accessed 20 August 2007. Back

48   Op cit (no 40). Back

49   Royal College of Obstetricians and Gynaecologists, The Care of Women Requesting Abortion (London: RCOG Press, 2004). Back

50   Grimes D, "Risks of mifepristone abortion in context", Contraception, vol 71, no 3 (2005), 161 and Grimes D, "Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991-99", American Journal of Obstetrics and Gynecology, vol 194, no 1 (2006), 92-94. Back

51   Confidential Enquiry into Maternal and Child Health, Why Mothers Die: 2000-02 (London: RCOG Press, 2004). Back

52   Op cit (no 49). Back

53   Op cit (no 49). Back

54   Op cit (no 49). Back

55   Op cit (no 49). Back

56   Op cit (no 49). Back

57   Marie Stopes International, General Practitioners: attitudes to abortion (London: MSI, 1999). Back

58   Finnie S, Foy R and Mather J, "The pathway to induced abortion: women's experiences and general practitioner attitudes", Journal of Family Planning and Reproductive Health Care, vol 32, no 1 (2006), 15-18. Back

59   Marie Stopes International, Late Abortion: A Research Study of Women Undergoing Abortion Between 19 and 24 Weeks' Gestation (London: MSI, 2005). Back

60   Ingham R et al, Second Trimester Abortions in England and Wales (Southampton: University of Southampton, 2007). Back

61   Goldman M B et al, "Physician assistants as providers of surgically induced abortion services", American Journal of Public Health, vol 94, no 8 (2004), 1352-1357. Back

62   Warriner I K et al, "Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial", The Lancet, vol 398, 2 December (2006), 1965-1972. Back

63   Danco Laboratories, Mifeprex Patient Brochure 2007 (New York: Danco Laboratories, 2007), <http://www.earlyoptionpill.com/pdfs/Combined-English.pdf>, accessed 20 August 2007. Back

64   Schaff E A et al, "Vaginal misoprostol administered at home after mifepristone (RU486) for abortion", Journal of Obstetrics and Gynecology, vol 24, no 2 (2004), 155-156. Back

65   Shannon C S et al, "Multicenter trial of a simplified mifepristone medical abortion regimen", Obstetrics and Gynecology, vol 15, no 2 (2005), 345-351. Back

66   Hamoda H et al, "The acceptability of home medical abortion to women in UK settings", BJOG, vol 112, no 6 (2005), 781-785. Back

67   Hamoda H et al, "Home self-administration of misoprostol for medical abortion up to 56 days' gestation", Journal of Family Planning and Reproductive Health Care, vol 31, no 3 (2005), 189-192. Back

68   Clark W H et al, "Home use of two doses of misoprostol after mifepristone for medical abortion: a pilot study on Sweden and France", European Journal of Contraception and Reproductive Health Care, vol 10, no 3 (2005), 184-191. Back

69   Elul B et al, "In-depth interviews with medical abortion clients: thoughts on the method and home administration of misoprostol", Journal of the American Medical Women's Association, vol 55, no 3 (suppl 2000), 169-172. Back

70   Glasier A et al, "Sexual and reproductive health: a matter of life and death", The Lancet, vol 368, 4 November (2006), 1595-1607. Back

71   Ibid. Back

72   72 International Planned Parenthood Federation, Death and Denial: Unsafe Abortion and Poverty (London: IPPF, 2006). Back

73   Op cit (no 15). Back

74   Marie Stopes International, Nepal: New Figures Show Safe Abortion Services Help to Dramatically Reduce Maternal Deaths MSI press release, 18 July 2007, <http://www.mariestopes.org.uk/ww/press/press-ww-180707.htm>, accessed 4 August 2007. Back

75   Collaborative Group on Hormonal Factors in Breast Cancer, "Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83,000 women with breast cancer from 16 countries", The Lancet, vol 363, 27 March (2004), 1007-1016. Back

76   Op cit (no 13). Back

77   Thorp J M, Hartmann K E and Shadigian E, "Long-term physical and psychological health consequences of induced abortion: review of the evidence", Obstetrical and Gynecological Survey, vol 58, no 1 (2002), 67-79. Back

78   Op cit (no 13). Back

79   Op cit (no 41). Back

80   Cohen S, "Abortion and mental health: myths and realities", Guttmacher Policy Review, vol 9, no 3 (2006), www.guttmacher.org, accessed 3 August 2007. Back

81   Ibid. Back

82   Dagg P, "The psychological sequelae of therapeutic abortion-denied and completed", The American Journal of Psychiatry, vol 148, no 5 (1991), 578-585. Back

83   Ibid. Back


 
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