Memorandum 29
Submission from Royal College of Obstetricians
and Gynaecologists
As part of their inquiry into scientific developments
relating to the Abortion Act 1967, the Science and Technology
Committee invited comments on three areas. In response, the Royal
College of Obstetricians and Gynaecologists is pleased to submit
the following.
1. THE SCIENTIFIC
AND MEDICAL
EVIDENCE RELATING
TO THE
24-WEEK UPPER
TIME LIMIT
ON MOST
LEGAL ABORTIONS,
INCLUDING:
1.1 Developments, both in the UK and internationally
since 1990, in medical interventions and examination techniques
that may inform definitions of foetal viability
1.1.1 The major development since the 1990
modification to the Abortion Act has been an improvement in the
survival of babies born at 24 weeks. Table 41 provides data from
1995. This shows that 26% of babies born at 24 weeks survived
to discharge. Additional data relating to 2006 will be available
shortly when the results of the EPICure-2 study are published.
However regional data from the Trent Survey (unpublished personal
communication) suggests that survival in the last 10 years has
risen to 40% of neonatal intensive care admissions at 24 weeks,
although there has been little improvement in survival at gestations
below this.
1.1.2 If the gestational age limit for termination
of pregnancy under Clauses C and D were lowered this would be
close to the gestational age at which detailed scans are undertaken
to confirm or refute earlier findings. For example, fetal cardiac
scans are frequently done at 22 to 23 weeks in women with a suspicious
prior scan. This is because the images of the fetal heart anatomy
are better at the later gestational age. Having a gestational
age limit for termination shortly after the time of this detailed
anomaly scan could have the effect of increasing the rate of termination
if patients are not prepared to accept any risk. One of the advantages
of late termination of pregnancy under Clause E is that patients
with abnormalities of uncertain significance (eg mild ventriculomegaly)
can continue their pregnancy until the prognosis becomes clearer,
in the knowledge that late termination of pregnancy for a severe
outcome will still be available.
1.1.3 The College has under frequent review
its report on fetal awareness, and although this was published
some time ago is aware of no new evidence relevant to alteration
of current abortion practice as outlined in the RCOG Guideline
The Care of Women Requesting Induced Abortion.
1.2 Whether a scientific or medical definition
of serious abnormality is required or desirable in respect of
abortion allowed beyond 24 weeks
1.2.1 There seems to be little reason to
change the current law regarding the definition of serious abnormality.
A strict definition is impractical for two reasons. Firstly, we
do not have sufficiently advanced diagnostic techniques to always
(i) precisely define the abnormality and (ii) predict the "seriousness"
of the outcome, albeit that the 1996 RCOG Report on Termination
of Pregnancy for Fetal Abnormality provides helpful guidance on
the scaling of severity. This states that both the size of the
risk and the gravity of the abnormality are important.
1.2.2 Secondly, the outcome can have serious
consequences not only for the fetus in terms of viability or residual
disability (which can be physical, intellectual or social), but
also for the child or for the family into which the child would
be born. 2,3 Thus a "serious abnormality" should be
based upon individual discussion agreed between the mother and
the most senior clinician taking into account all clinical information
available (obstetric and other relevant specialists eg paediatric)
and the wishes of the mother (ideally parents). The difficulties
in this area and the effects on the mother and the family require
clinical care of the highest standard and experience.
2. MEDICAL, SCIENTIFIC
AND SOCIAL
RESEARCH RELEVANT
TO THE
IMPACT OF
SUGGESTED LAW
REFORMS TO
FIRST TRIMESTER
ABORTIONS, SUCH
AS:
2.1 The relative risks of early abortion versus
pregnancy and delivery
2.1.1 The evidence suggests that termination
of pregnancy in the first trimester (done in an appropriate healthcare
setting) is associated with a reduced mortality and morbidity
risk compared to continuing the pregnancy. This means that women
in the first trimester could be seen as automatically fulfilling
the criteria of the Abortion Act. Although this was not the original
intention of the Act, in practice it facilitates access to induced
abortion within the current law.
2.2 The role played by the requirement for
two doctors' signatures
2.2.1 It is assumed that two signatures
were put into the 1967 Abortion Act to show the seriousness of
the decision to terminate rather than to maintain clinical standards.
It may be appropriate to continue to involve two appropriately
trained and experienced clinicians in more complex cases (eg late
fetal abnormality, the very young and those with learning disabilities).
However, the current use of the Abortion Act by the population
and the profession (98% are done under clause C or D) suggests
that, in the majority of cases, the need for two signatures is
anachronistic. Overall, women support the right to abortion and
the GMC guidance that alternative provision must be offered if
the practitioner cannot support a request for abortion is evidence
for the woman's autonomy to seek help. The refusal to sign HSA1
does not prevent a woman from going to another provider for a
signature.
2.2.2 The disadvantage of obtaining two
signatures is that it has the potential to cause delay which can
increase clinical risk. Women commonly have to find a doctor who
will refer and they may or may not provide a signature. Furthermore,
some services send women back to their GPs for the second signature
when the abortion has been granted. If the GP does not provide
the second signature, this causes delay, which may cause additional
stress to the woman who is already distressed. It does not make
sense for the system to cause additional distress and delay unless
there is a benefit in obtaining two signatures.
It has been argued that some delay is a good
thing since it allows women more time to reflect on the decisions
about abortion. There is good evidence that the vast majority
of women who are referred for abortion are absolutely certain
that the pregnancy is unwanted and have no doubts about wanting
the procedure. This fact was clear even in the early 1980s when
in an interview study of over 200 women undergoing abortion, only
6% said that they had been unsure of their decision and only 3%
admitted to having wanted to conceive.4 Two more recent studies
undertaken in Scotland using a validated measure of pregnancy
intention and using either interviews5 or self-administered questionnaires6
have shown that 90% of pregnancies that end in therapeutic abortion
were clearly unintended. The suggestion that the need to have
two doctors sign the form would help those women who do have some
doubt about abortion to make up their minds seems unpersuasive.
If there are concerns that a few women who are unsure of the decision
would "slip through the net", the use of the simple
intended-ness tool used in two of the studies5,6 would be a much
more scientific and efficient way to identify women at risk of
regretting the decision to proceed with abortion.
2.3 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
2.3.1 Many hospital based abortion services
already rely on nurses to run their medical abortion units. Allowing
nurses to take consent for abortion (medical or surgical) would
help to make these services run more efficiently. There is no
reason why a properly trained nurse should not be competent to
obtain consent to abortion, although this role should not be taken
over by clinical ethics committees or bureaucratic review processes
(as occurs in France, Israel and Western Australia). A recent
Randomised Controlled Trial published in the Lancet has shown
that first trimester abortion using manual evacuation can be provided
safely by appropriately trained nurses.7 If medical abortion can
be undertaken safely at home (see below), it can certainly be
supervised by nurses.
2.3.2 Managing a woman in the abortion service
requires a number of clinical skills which nurses have demonstrated
in other healthcare settings. For example most services use routine
ultrasound scanning to determine gestation and eligibility for
medical or surgical abortion. Nurses are now trained to undertake
these and other similar procedures (eg colposcopy and cervical
surgery), which require similar skills and judgement.
2.3.3 Regarding abortion at home, there
is an increasing body of evidence from both developed and developing
countries that home use of mifepristone/misoprostol is safe, effective
and acceptable to many women. 8-12 More work is needed to assess
safety and acceptability in the UK context, but this would require
a change in the current law or a different interpretation of the
abortion process within the current law.
3. EVIDENCE OF
LONG-TERM
OR ACUTE
ADVERSE HEALTH
OUTCOMES FROM
ABORTION OR
FROM THE
RESTRICTION OF
ACCESS TO
ABORTION
3.1 There are a number of publications on
the physical risks of abortion in the short and long term (eg
infection, haemorrhage, injury, infertility, miscarriage, preterm
delivery). There seems to be no increased risk of certain complications
such as breast cancer. Many of the studies on outcomes have methodological
problems, for example the patients studied are unrepresentative
of the population, and it is often difficult to obtain an appropriate
control group. These issues are discussed in the RCOG Abortion
Guideline.
3.2 Adler gave evidence to the U.S. House
of Representatives (March 16, 1989) 13 in which she stated that
studies demonstrate that the predominant feeling following abortion
is one of relief and diminution of stress. The incidence of severe
negative reactions is low, although some factors are known to
increase risk (eg abortion when the pregnancy had been planned
and late gestation abortion). 14,15 Subsequent studies tend to
support this view as indicated in the RCOG Abortion Guideline.
Where problems do arise there is often a history of susceptibility
which predates the abortion procedure. Again studies in this area
suffer from a difficulty of adequate controls as clearly demonstrated
in the recent New Zealand study.
4. CONCLUSION
The College does not feel the upper gestational
limit of 24 weeks should be lowered on the basis of recent improvements
on fetal viability. This would restrict the option of termination
in some particularly difficult cases. The decision about the seriousness
of the abnormality in a fetus is best left to discussion among
parents and specialists. Practitioners no longer feel that the
signatures of two doctors are necessary to proceed with an abortion.
By and large long term follow up studies of physical and psychological
sequelae, harmful effects or reproductive outcomes following abortion
are reassuring. Furthermore there is no evidence that medical,
as opposed to surgical methods, are different in this respect.
The College is commissioning further work to update current guidelines
which address a number of these issues, including fetal awareness
and long term sequelae.
Table 4
SUMMARY OF OUTCOMES AMONG EXTREMELY PRETERM
CHILDREN*
| Outcome | 22 Wk (N = 138)
| 23 Wk (N = 241) | 24 Wk (N = 382)
| 25 Wk (N = 424) number (percent) |
| Died in delivery room | 116 (84)
| 110 (46) | 84 (22) | 67 (16)
|
| Admitted to NICU | 22 (16) |
131 (54) | 298 (78) | 357 (84)
|
| Died in NICU | 20 (14) |
105 (44) | 198 (52) | 171 (40)
|
| Survived to discharge | 2 (1)
| 26 (11) | 100 (26) | 186 (44)
|
| Died after discharge | 0 |
1 (0.4) | 2 (0.5) | 3 (0.7)
|
| Lost to follow-up | 0 | 3 (1)
| 25 (7) | 39 (9) |
| At 6 year of age |
| Had severe disability | 1 (0.7)
| 5 (2) | 21 (5) | 26 (6)
|
| Had moderate disability | 0
| 9 (4) | 16 (4) | 32 (8)
|
| Had mild disability | 1 (0.7)
| 5 (2) | 26 (7) | 51 (12)
|
| Survived without impairment
|
| As a percentage of live live births | 0
| 3 (1) | 10 (3) | 35 (8)
|
| As a percentage of NICU admissions | 0
| 3 (2) | 10 (3) | 35 (10)
|
| Survived without severe or moderate disability
|
| As a percentage of live births | 1 (0.7)
| 8 (3) | 36 (9) | 86 (20)
|
| As a percentage of NICU admissions | 1 (5)
| 8 (6) | 36 (12) | 86 (24)
|
* NICU denotes neonatal intensive care unit.
REFERENCES
1. Marlow N, Wolke D, Bracewell MA, Samara M. Neurologic
and developmental disability at six years of age after extremely
preterm birth. N Engl J Med 2005;352(1):9-19.
2. David H P, Dytrych Z and Matejcek Z. Born unwanted:
observations from the Prague Study. American Psychologist 2003;
58: 224-229.
3. David H P. Born Unwanted, 35 Years Later: The Prague
Study. Reproductive Health Matters 2006; Volume 14; 27: 181-190.
4. Allen I. Counselling services for sterilisation and
termination of pregnancy. London: Policy Studies Institute No
641. 1985: 97-105.
5. Schunmann C, Glasier A. Measuring pregnancy intention
and its relationship with contraceptive use among women undergoing
therapeutic abortion. Contraception 2006; 73: 520-525.
6. Lakha F, Glasier A. Unintended pregnancy and use of
emergency contraception among a large cohort of women attending
for antenatal care or abortion in Scotland. Lancet 2006; 368:
1782-87.
7. Warriner IK et al. Rates of complications in first-trimester
manual vacuum aspiration abortion done by doctors and mid-level
providers in South Africa and Vietnam: a randomised controlled
equivalence trial. Lancet 2006; 368: 1965-72.
8. Clark WH, Hassoun D, Gemzell-Danielsson K, Fiala C,
Winikoff B. Home use of two doses of misoprostol for medical abortion—A
pilot study in Sweden and France. Eur J Contracep Reprod Health
Care 2005; 10:184
9. Clark WH, Gold M, Grossman D, Winikoff B. Can mifepristone
medical abortion be simplified? A review of the evidence and questions
for future research. Contraception 2007; 75: 245-250.
10. Fiala C et al Acceptability of home-use of misoprostol
in medical abortion. Contraception 2004; 70: 387-392.
11. Harper C et al. Could American women use mifepristone-misoprostol
pills safely with less medical supervision? Contraception 2002;
65:133-142.
12. Elul B, Hajri S, Ngoc NTN, Winikoff B, Ellertson
C, Ben Slama C, Pearlman E. Can women in developing countries
use a simplified medical abortion regimen of 200 mg mifepristone
followed by home administration of misoprostol? Lancet 2001; 357:
2001.
13. Adler N E. Statement on Behalf of the American Psychological
Association Before the Human Resources and Intergovernmental Relations
Subcommittee of the Committee on Governmental Operations, U. S.
House of Representatives, 16 March 1989: 130-140.
14. Adler N E, David H P, Major B N, Roth S H, Russo
N F, Wyatt G E. Psychological responses after abortion. Science
1990; 248 (4951): 41-44.
15. Adler N E, David H P, Major B N, Roth S H, Russo
N F, Wyatt G E. Psychological factors in abortion: A review. American
Psychologist 1992; 47 (10): 1194-1204.
September 2007
| 
