Submission from the Royal College of Nursing
1.1.0 The Royal College of Nursing (RCN)
welcomes the opportunity to make a submission to the Committee's
inquiry into the scientific developments relating to the Abortion
Act 1967. The RCN's response to this inquiry concerns abortion
services from a clinical perspective and does not specifically
examine the ethical issues surrounding abortion.
1.1.1 The RCN has hitherto supported the
availability of abortion under the current legislation. The Act
was originally passed to safeguard the lives of women with the
desire to end illegal and dangerous abortion and set out a range
of conditions and safeguards for women which included specifying
where abortions could take place, and under what circumstances.
The Act does not relate to Northern Ireland and therefore this
response does not refer to the current arrangements in place in
The RCN continues to support the
current law that enables abortion up to 24 weeks gestation.
The RCN believes that the requirement
for two doctors to agree that a women can have an abortion should
The RCN recommends a change or clarification
in legislation to allow nurses and midwives to be allowed to perform
early surgical abortions and to be able to prescribe Mifespristone
for early medical abortions as part of a clinical team.
The RCN recommends a change in the
British National Formulary (BNF) to allow independent nurse prescribers
to prescribe the abortion pill (Mifepristone).
The RCN would like to see clear standards
of care for all women seeking abortions to minimise the differences
in care in different locations.
The RCN recommends accredited appropriate
training for nurses and midwives who wish to work in a setting
where they are providing early abortion services.
The RCN believes that women should
have access to long acting reversible contraceptive (LARC) methods
as per the NICE guideline 2005.
The RCN would like to see that in
every provider unit, all women seeking abortion have access to
screening for STIs and treatment, if indicated, before their procedure
in order to reduce the incidence of pelvic inflammatory disease
(PID) post procedure.
Reducing the stigma around abortion
is vitally important. The RCN believes that the above recommendations
will contribute towards achieving this aim.
2.1 The RCN represents over 390,000 registered
nurses, midwives, health visitors, nursing students, health care
assistants and nurse cadets in the UK. This makes the RCN the
largest professional union of nursing staff in the world. The
College promotes patient and nursing interests on a wide range
of issues by working closely with government, the UK parliaments
and other national and European political institutions, trade
unions, professional bodies and voluntary organisations.
2.1.3 The RCN recognises that not of all
its members will feel comfortable with working in a service where
they might be or are required participate in abortion provision.
The RCN makes available guidance to its members on s.4 of the
Abortion Act (1967) which states that individuals are under no
obligation to "participate in any treatment authorised [by
the Act] to which [they have] a conscientious objection."
As an organisation we are here to support our members in providing
the very highest standards of care possible for their patients
and clients. We acknowledge and respect those nurses who have
a conscientious objection to providing abortion care but are committed
to providing support to those nurses who work in abortion care
to provide safe, effective and quality care.
2.2.0 Q 1 Scientific and medical evidence
relating to the 24-week upper time limit on most legal abortions,
2.2.1 A) Developments, both in the UK
and internationally since 1990, in medical interventions and examination
techniques that may inform definitions of foetal viability
2.2.2 One of the key technological developments
since 1990 has been the ability to view the developing foetus
in increasing detail via 3D and 4D ultrasound scanning. These
images provide a three-dimensional view of the foetus and have
been used to demonstrate the close resemblance of the foetus to
a neonate, in an attempt to strengthen the claims of those opposed
to abortion that killing a foetus is analogous to killing a neonate.
The RCN's view is that 3D and 4D imaging only serves to reveal
what is already known, but with greater clarity.
2.2.3 Improvements in neonatal care have
led to unrealistic expectations about the medical ability to sustain
life at early gestation. Survival rates for babies born very early
remain low; at 21 weeks gestation zero percent survive; at 22
weeks 10% survive and just 26% survive at 24 weeks (Costeloe et
al 2000). Survival in itself does not, of course, determine quality
of life, which can be considerably affected by premature birth.
2.2.4 Currently 90% of abortions are carried
out before 13 weeks and 98% are carried out under 20 weeks. Only
a very small proportion of abortions, just two percent, are carried
out after 20 weeks. There are a number of reasons why women present
at this late stage. They include young women in denial of their
pregnancy, older women who have not had a period for a long time
or are in the early stages of menopause unaware that they could
be pregnant, women using the Depo Provera contraception injection
which causes amenorrhea, or women for whom there has been a difficult
change in personal circumstances. (Pro-choice forum. Late abortion:
a review of the evidence. 2004)
2.2.5 There are no developments in technology
to suggest that viability has altered, yet being able to perform
an abortion up to twenty-four weeks is of enormous importance
to this very small but important group of women. The RCN continues
to support the current legislation that enables abortion up to
2.3.0 B) Whether a scientific or medical
definition of serious abnormality is required or desirable in
respect of abortion allowed beyond 24 weeks
2.3.1 In 2006 only 2000 (one per cent) of
abortions were carried out under section E of the Abortion Act
1967. (Department of Health Statistical Bulletin. Abortion Statistics:
England and Wales 2006). The social implications that determine
a definition of "abnormality" and the inherently subjective
components of such a definition must be taken into consideration
and the RCN believes that they should, in many instances, outweigh
a scientific or medical definition when making decisions regarding
3.1.0 Q2 Medical, scientific and social
research relevant to the impact of suggested law reforms to first
trimester abortions, such as:
3.1.1 A) The relative risks of early
abortion versus pregnancy and delivery
3.1.2 The National Strategy for Sexual Health
and HIV (Department of Health 2001) set a target that women seeking
abortion should have access to this service within three weeks
and this was further recommended by the Medfash Standards for
Sexual Health in 2005. Evidence suggests that abortion is safe
but complications and risk increase as gestation progresses, therefore
the earlier in pregnancy an abortion takes place the safer it
is for the woman. However, regardless of gestation; abortion is
safer than pregnancy and delivery (RCOG. The care of women requesting
induced abortion. 2004; 23). This is reflected in the NHS QIS
Scottish Standards for TOP (June 2007).
3.1.3 The reported complication rates for
abortion are about two in every 1000 abortions (ibid.). Conversely,
only 47% of deliveries are classed as "normal" and complications
occurring in the ante, intra and post partum period are numerous.
(NHS Information Centre 2007. Maternity Statistics England 2005-06)
Moreover it could be argued that the relative risk of abortion
has decreased since the introduction of medical abortion. (First
Trimester Abortion: a briefing paper by the BMA's medical ethics
committee BMA, 2007)
3.2.0 B) The role played by the requirement
for two doctors' signatures
3.2.1 Seeking an abortion requires that
the woman's consent is both fully informed and autonomously given,
however, under the existing law, abortion remains a crime under
s.58 and s.59 Offences Against the Persons Act 1861 and the Infant
Life Preservation Act 1929, for which the Abortion Act 1067 provides
a set of defences. The law hands over responsibility to doctors
to make the judgement about whether any of these defences apply.
(Paton v Trustees of BPAS p992; C v S  1 All ER 1230).
3.2.2 In R v Smith  Lord Justice Scarman
noted: "The Act, though it renders lawful abortions that
before its enactment would have been unlawful, does not depart
from the basic principle ... that the legality of an abortion
depends on the opinion of the doctor."
3.2.3 The requirement for the opinion of
the doctor is a risk assessmentthat the balance of the
risk between termination and continuation of the pregnancyhas
been contemplated by a doctor. Montgomery argues that "this
is reinforced by the fact that the Abortion Act makes a legality
of a termination depend, not on whether the grounds are actually
made out, but whether two doctors believe that they are in good
faith" (Montgomery J. p.383, Health Care Law 2nd edition,
3.2.4 The current requirement of two medical
practitioners' signatures is not only out-dated but can lead to
delays in the referral process for women and therefore increases
the risk as gestation progresses.
3.2.5 There is no other medical or surgical
procedure which requires the consent of a medical practitioner
or the signature of two doctors before it is carried out. It is
demonstrable that the requirement is simply a paper exercise.
The RCN believes that a competent woman seeking an abortion is
able to give informed consent to any procedures carried out (excepting
medical emergencies that may arise where this is not possible).
Her consent would be based upon an explanation and understanding
of the available methods of abortion including complication rates
and follow-up care.
3.2.6 The RCN further believes that the
request for abortion should be made by the woman and not by two
doctors on her behalf. Therefore the RCN believes that the requirement
for two doctors to sign consent for an abortion should be removed
from the legislation.
3.3.0 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 a patient's home
3.3.1 Nurses and midwives are currently
providing high quality, patient centred nursing care within abortion
services offering physical, emotional and social care and support
to women and their families. Nurses working within these services
wish to improve access and ensure women receive a safe, effective
and seamless service with the least delay.
3.4.1 Surgical abortion
When the Abortion Act was passed in October
1967 it was not common practice for nurses and midwives to perform
surgical procedures; however nurses and midwives have expanded
on their practice and now perform a range of complex procedures
including colposcopies and hysterosopies, and fitting intrauterine
devices (IUDs) and sub-dermal implants.
3.4.2 There is a lack of clarity in the
legislation. The Abortion Act states that a legally induced abortion
must be performed by a registered medical practitioner. Previous
cases (RCN v DHSS 1981) have examined what "registered medical
practitioner" means in relation to medical abortion. However,
the interpretation of "registered medical practioner"
to include nurses and midwives for the purposes of performing
surgical abortions has been rejected by the Department of Health.
3.4.3 The RCN believes that registered nurses
and midwives with appropriate training and who are appropriately
accredited in abortion care should be allowed to perform early
surgical abortions. The RCN believes that this should could be
addressed either by expanding the definition of "registered
medical practioner" in the legislation or by allowing a broader
interpretation under the existing wording.
3.4.4 In these circumstances, the RCN believes
that nurses and midwives should be part of a team in providing
care. They should have the clinical support of a registered medical
practitioner who is an expert in the field and be part of the
whole team providing abortion. (First Trimester Abortion: a briefing
paper by the BMA's medical ethics committee BMA, 2007)
3.5.0 Early medical abortion
3.5.1 In many services nurses and midwives
already provide the total care package to women having early medical
abortion with the exception of being able to prescribe the medication
needed. Mifespristone is listed in the BNF for Nurse Independent
Prescribing (NIP) but cannot be prescribed by nurses in abortion
cases. Allowing nurses and midwives to extend their role would
prevent women in some parts of the UK being delayed in seeking
an early abortion.
3.6.0 Early medical abortion second stage
3.6.1 Whilst it is becoming common practice
to carry out abortions in the home in the USA, this practice has
not been evaluated in the UK. Without evaluation it is not possible
to recommend this practice at this stage.
3.6.2 A survey amongst women in 2006 which
was sponsored by the fpa found that whilst 71% of those questioned
thought that all procedures that took place in the hospital could
be provided in the home, sixty-four per cent indicated that they
would prefer to undergo an abortion in a hospital (Hamoda, 2005).
4.1.0 Q 3) Evidence of long-term or acute
adverse health outcomes from abortion or from the restriction
of access to abortion
4.1.1 It has been reported that the incidence
of psychological sequelae following abortion is rare and as such
there is no scientific evidence for the often used phrase "post-abortion
syndrome". (Schmeige S, Russo N. Depression and unwanted
first pregnancy: longitudinal cohort study. BMJ 28.20.2005)
4.1.2 The emotional distress following an
abortion is related to the degree of emotional distress before
the abortion and can be linked to issues that may have contributed
to the request for abortion. (National Abortion Federation. www.pro-choice.org/about_abortion/myths/post_abortion_syndrome)
4.1.3 It is very difficult to calculate
adverse health outcomes from abortion or from the restriction
of access to an abortion. There is currently no written evidence
on this issue. One of the reasons for this is that, as with other
aspects of sexual reproductive health, service users are unlikely
to complain if they receive poor standard of care. It is also
difficult to pinpoint what the cause of any adverse health outcomes
may have been, as the difficult personal, social and psychological
circumstances that let to the abortion rather than abortion itself
may be the cause of mental health problems.
4.1.4 Some women report difficulties in
their journey through the abortion process. There are a number
of reasons for this. The current need for two signatures can cause
delay unintentionally. It has also been reported anecdotally that
some GPs who are personally not in favour of abortion may delay
the referral, for example, by making the women have a pregnancy
test first and then waiting several weeks to reveal the result.
Other women may experience delays due to the provision of local
services or lack of funds. Such delay may have a negative impact
on health outcomes. The outcome for women in these circumstances
is often traumatic and adds to feelings of guilt that some may