Select Committee on Science and Technology Written Evidence

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


  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


  "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


  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.


  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


  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


  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.


  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


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.

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.

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