Memorandum 18
Submission from the Faculty of Family
Planning and Reproductive Health Care
The Faculty of Family Planning and Reproductive
Health Care would like to submit the following response to Science
and Technology Committee inquiry into scientific developments
relating to the Abortion Act 1967.
The Faculty was established in 1993 as a faculty
of the Royal College of Obstetricians and Gynaecologists. The
Faculty promotes training and excellence in contraception and
reproductive healthcare; granting diplomas, certificates, fellowships
and equivalent recognition of specialist knowledge and skills
in Sexual and Reproductive Healthcare (SRH).
Members provide services in both general practice
and community services, playing a major role in providing specialist
advice for contraception and 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 foetal viability
FACULTY RESPONSE
It is clear that there have been advances in
the support services to Obstetrics and access to the foetus and
foetal tissue for diagnosis and treatment, supported by ultrasound,
is greatly improved.
Ultrasound scans early in pregnancy are much
more accurate at diagnosing intrauterine pregnancy and confirming
gestation and viability. A wider range of foetal abnormalities
can be detected, or refuted, and there is increased capacity for
treatment of the foetus in utero and baby post delivery.
However, the conclusive diagnosis of serious
foetal abnormality may still take late into the second trimester
or later, and for women who feel they cannot continue with such
a pregnancy, the need for later abortion procedures continues.
These technical advances have also brought into question the foetus'
ability to experience pain, foetal movements and expressions being
attributed to "feeling". The evidence to date is limited
but a thorough review of the scientific evidence published in
the Journal of the American Medical Association in 2005 concluded
that the perception of pain is unlikely below 24 weeks gestation
(22 weeks from conception); for example cutaneous withdrawal reflexes
and hormonal stress responses present earlier in development not
being explicit or sufficient evidence of pain perception and giving
evidence for this statement.1
(b) whether a scientific or medical
definition of serious abnormality is required or desirable in
respect of abortion allowed beyond 24 weeks
FACULTY RESPONSE
"Required or desirable": we believe
it is desirable but has to be accepted it is not always achievable,
ie to confirm whether there is or is not a serious abnormality,
on two grounds:
1. Precisely defining the abnormality will
not always be possible; as we do not have sufficiently advanced
diagnostic techniques to know we will always be able to a) precisely
define the abnormality and b) predict the "seriousness"
of the outcome
2. Definition of the word "serious".
Serious to whom? Serious to the foetus in terms of viability or
residual disability (which can be physical, intellectual or social)
in the child or serious to the family into which the child would
be born; a family rejecting of a child unwanted due to disability
can result in poor outcomes in the child (ref Czech study17)
An exhaustive list of "serious abnormality"
is unachievable for the reasons given in both 1 and 2 above; who
can define what is serious? Having a foetus/child with the absolute
diagnosis of a known abnormality eg trisomy 21 is still an unknown
quantity, from how much one/other/both parents can love the child
and give the life every child deserves to how severely affected
the foetus/child will be physically, emotionally and socially.
We believe you cannot put a scientific definition
on "serious abnormality" but you can put a medical one
based on what is agreed between the mother of the pregnancy and
the consultant in charge of her case, taking into account all
clinical information available (obstetric and with information
from other pertinent specialists eg paediatrician) and the wishes
of the mother (ideally parents but ultimately the decision lies
with the mother). This situation would benefit from having national
clinical guidelines /standards set, laying out what information
should be available and what staff are involved; there is also
good argument not to involve the clinician in charge of the case
if this clinician is opposed to abortion, as some are.
References for this would be the Czech study17
and references to improvements in diagnostic techniques (not supplied).
If a strict definition of serious abnormality
cannot be achieved because of its complex nature, then it cannot
be made a requirement.
2. Medical, scientific and 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
FACULTY RESPONSE
There are many references (scientific evidence)
in the literature as to the relative physical safety of first
trimester abortion, as compared to term delivery, given both are
undertaken in safe conditions2.
A paper this year in the New England Journal
of Medicine3 reported lack of evidence for early medical abortions
increasing the risk of spontaneous abortion, ectopic pregnancy,
preterm birth, or low birth weight in subsequent pregnancy compared
to early surgical abortions. There is the defined condition "post
natal depression" accepted by psychiatrists; however psychiatrists
have yet to define a "post abortion syndrome". The US
House of Representatives Committee on Government Operations (1989)
under Surgeon General Koop failed to find evidence for this syndrome4.
No overall increase in psychiatric morbidity was found in an English
study5. Research proposes that severe negative reactions are rare
and can best be understood in the framework of coping with a normal
life stress6.
(b) the role played by the requirement
for two doctors' signatures
(1) The role played by two doctors' signatures.
FACULTY RESPONSE
Our understanding is that two signatures were
put into the 1967 Abortion Act to show the seriousness of the
decision to terminate. It is not there to maintain clinical standards;
these are maintained through informed consent and the adherence
to Good Practice Guidelines, such as those of the Royal College
of Obstetricians and Gynaecologists.
We would argue that if the issue is the maintenance
of standards, then that is addressed by commissionable and performance
managed national clinical guidelines. There is an argument to
wish the involvement of two appropriately trained and experienced
doctors in more complex cases, eg foetal abnormality, the very
young and the vulnerable to evidence the case has been given the
clinical involvement it merits. If this were to be the case, good
practice may suggest there are professionals as appropriate as
doctors to fulfil this role. However, this involvement is nothing
to do with signing the HSA1 which is not just one but two persons
having the right to have the ultimate say of what is or is not
in the interest of another consenting person (who by definition,
in the vast majority of cases, has been judged competent to weigh
all pros and cons and reach a conclusion herself, ie is fit to
give informed consent).
We know of no scientific or medical evidence
supporting the need for two medical signatures and question the
right of any person to veto the rights of a competent other to
make decisions about their own health and wellbeing. Nevertheless,
we feel that one signature is required to evidence the gravity
of the request and the overt support of the physician.
The current use of the Abortion Act by the population
and the profession (98% are done under clause C or D, though this
is all gestations) is on its own evidence that the two signatures
are anachronistic. Doctors can sign having never seen or examined
the woman. Overall, polls show women support the right to abortion7.
The GMC Guidance that if a doctor cannot support a request for
abortion, alternative provision must be offered is also evidence
for the belief in a woman's autonomy to seek help. The refusal
to sign HSA1 does not prevent a woman from going to another provider
for a signature.
Good clinical standards are essential but a
separate issue. The debate on how to show the seriousness of the
procedure is a moral one and outwith the declared scope of this
paper.
I know of no research in this area, ie the role
played by the Doctor with regards to HSA1 but there are surveys
illustrating women's attitudes, opinions and wants.
(2) Issues with the two doctors signatures
FACULTY RESPONSE
One signature can cause delay. so the need for
two signatures has the potential to cause further delay. However,
it is difficult to tease out how much and how often delay is related
to signatures. Nevertheless, delay increases clinical risk2 and
may prevent access to early medical abortion (as opposed to surgical).
Women commonly have to find a doctor who will refer; yet few NHS
provided services have self referral (unless you consider access
via a Family Planning service self referral). The referring doctor
may or may not provide a signature.
Nurse-led services by definition cannot provide
signed HSA1s with referral. If this doctor/the service referred
to is not efficient, time is lost while the signature is sought
(good services eg Liverpool, Portsmouth, Hull, bpas, ensure signatures
as part of the service but this does not have to be the case).
Moreover, some services send women back to their GPs for the second
signature when the abortion has been granted by the provider service.
However what does that woman do if her GP will not sign? No second
signature, no procedure equals delay. Plus she has the stress
of finding another signatory.
Furthermore, two signatures have the potential
for causing further stress to the woman who is already distressed.
She goes to someone to ask for referral and risks being made to
feel bad about herself/turned away and told to go elsewhere, a
cause of short-term distress.8 It could be argued that this is
about service provider attitude and nothing to do with HSA1s but
right now most women access abortions through their GPs or Family
Planning clinics (women will guess access is available via the
GP but many are not aware of access through their FP service9)
and do not know the GP/FPs' clinicians stance on the topic10 (this
alone is stressful) 11. It therefore does not make sense, in the
absence of any evidence otherwise, for the system per se to be
a source of distress and possible delay unless it is shown there
is the need for two signatures.
(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
FACULTY RESPONSE
Nurses and midwives in the UK already take part
in many aspects of abortion care. Many early medical abortion
services are increasingly nurse led (apart from the parts which
they are legally not allowed to participate in) and nurses and
midwives undertake patient care in late medical abortion.
There is a lot of clinical research from around
the world on this topic. The procedures nurses are allowed to
do vary from state to state in the United States. As of January
2004, trained advanced practice clinicians were providing medical,
and in some cases, early surgical abortion in 14 states12. Nurses
and midwives run services in South Africa with excellent safety
profiles13. Moreover nurses already undertake highly skilled surgical
services; in gynaecology, appropriate examples are nurse advanced
hysteroscopists and colposcopists.
Given the evidence, we consider enabling trained,
competent nurses/midwives to carry out early surgical procedures,
with appropriate back-up should emergencies arise, as with medical
practitioners, is entirely suitable for service provision.
The evidence is that it is perfectly safe for
the second stage of early medical abortion to be carried out at
home within the structure of properly organised services. 14
3. Evidence of long-term or acute adverse
health outcomes from abortion or from the restriction of access
to abortion.
FACULTY RESPONSE
There are many publications on the physical
risks of abortion in the short and long term (infection, haemorrhage,
injury, in the short term, infertility secondary to pelvic infection
(not the abortion procedure) in the long term; debate on increased
risk of miscarriage and pre-term delivery is heavily clouded by
confounding factors. There is no evidence of increased risk of
ectopic pregnancy, placenta praevia or breast cancer.). These
are well quantified and presented, along with actions to minimise
risk, in the RCOG Guidelines on Abortion2. What quality research
has been published since the Guideline does not alter this statement.
There are a few good studies, together with
a lot of published poor studies on the adverse long-term psychological
outcomes eg the samples are not representative of the population.
The American Psychological Association and American
Psychiatric Association do not recognise "Post Abortion Syndrome"
through lack of evidence.
Adler has given evidence to U.S. House of Representatives
(March 16, 1989) 15 in which she summarises studies by saying
the predominant feeling following abortion is relief and happiness,
the incidence of severe negative reaction is low and factors are
known which put women at greater risk (eg planned pregnancy, 2nd
trimester procedures, partly due to the nature of women accessing
later abortions, poor support). She published on the emotional
responses following abortion, positive and negative.8 The Koop
Report could find no conclusive evidence for mental health problems4.
There is not a lot of recent clinical study
on restriction to access. A paper from the UK on a large cohort
study (13 000 women) by GPs reporting psychiatric morbidity showed
psychiatric disorder no higher after abortion than pregnancy.5
Pre-existing psychiatric illness was a risk for both groups. The
abortion group showed more deliberate self harm but greater in
those refused an abortion, indicating confounding variables such
as adverse social factors. A Swedish survey showed the denial
of an abortion caused significant disturbance of the woman at
18 months in 24% and 31% were providing a notably unfavourable
environment for their children. 16 Regards the effect on the children,
the best is probably the Czech study (Born Unwanted, 35 years
later17) which showed less breast feeding, more childhood illness,
behavioural problems and poorer school performance and when these
children reached their 20s they had more social problems, job
dissatisfaction, fewer friends, more criminality and drug and
alcohol problems. We have not searched the literature for adverse
outcomes of for the mother or child when the child was given up
for adoption.
September 2007
REFERENCES
1. Lee SJ et al. Foetal pain: a systematic multidisciplinary
review of the evidence. JAMA 2005; 294: 947-54 and correspondence
JAMA 2006;2 95:159-161.
2. Royal College of Obstetricians and Gynaecologists.
The Care of Women Requesting Induced Abortion. National Evidence-based
Clinical Guidelines. 2004. www.rcog.org.uk
3. Virk J et al. Medical abortion and the risk
of subsequent adverse pregnancy outcomes. N Engl J Med 2007;357:
648-53.
4. Medical and Psychological Impact of Abortion.
Hearing before the Human Resources and Intergovernmental Relations
Subcommittee of the Committee on Government Operations House of
Representatives. One Hundred First Congress.
5. Gilchrist AC et al. Termination of pregnancy
and psychiatric morbidity. B J Psych 1995; 167: 243-8.
6. Adler NE et al. Psychological responses after
abortion. Science,1990 248, 41-44.
7. Women's perceptions of abortion law and practice
in Britain, 2002. Independent survey by BMRB Social Research for
Marie Stopes. This gave little support for doctors having anything
but a consultative role in decisions relating to fertility regulation.
8. Adler NE (1975) emotional responses of women
following therapeutic abortion. Am. J. Orthopsychiatry 45(3) 446-454.
9. A Quest for Abortion; Research from Voice
for Choice presented at the All-Party Parliamentary Pro-Choice
Group, December 1999.
10. Obstruction by clinicians but not to do with
two signatures specifically; Late; a study of women undergoing
abortion between 19 and 24 weeks. MSI 2004.
11. Case studies from General Practitioners Attitudes
to Abortion. A report by MSI. June 1999
12. Joffe C, Yanow S. Advanced practice clinicians
as abortion providers: current developments in the United States.
Reprod. Health Matters.2004;12 (24 suppl):198-206.
13. Warriner IK et al. Rates of complications
in 1st trimester manual vacuum aspiration done by doctors and
mid-level providers in South Africa and Vietnam. Lancet 2006;368:1965-72.
14. Fiala C et al. Acceptability of home use
of misporostol in medical abortion. Contraception; 2004.70:387-92.
15. Statement of Nancy E Adler. For: Medical
and Psychological Impact of Abortion. Hearing before he Human
Resources and Intergovernmental Relations Subcommittee of the
Committee On Government Operations House Of Representatives. One
Hundred First Congress. 1st session. 16 March 1989.
16. Hook K. Refused abortion. Acta Psychiatrica
et Neurologica Scandinavica 1963; 39 suppl 168:3-156.
17. David HP. Born Unwanted, 35 years later:
the Prague Study. Reprod. Health Matters. 2006;14: 181-90.
| 
