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
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providers in South Africa and Vietnam: a randomised controlled
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(2006), 1965-1972. Back
63
Danco Laboratories, Mifeprex Patient Brochure 2007 (New
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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
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69
Elul B et al, "In-depth interviews with medical abortion
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70
Glasier A et al, "Sexual and reproductive health: a matter
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(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",
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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,
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83
Ibid. Back
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