Memorandum 34
Submission from Christian Medical Fellowship
EXECUTIVE SUMMARY
1-4. We introduce Christian Medical
Fellowship's status, submissions, and relevant core beliefs. We
regret the exclusion of an ethical dimension to the consultation,
the short time scale, and the brevity required.
5-7. Upper time limit—survival
has improved year-on-year for extremely preterm infants born at
24 weeks" gestation or less. We should be careful using historical
data when considering the present and the future. Parliament should
review the 24-week upper time limit on most legal abortions.
8-10. Definitions—neither
Parliament nor the courts have defined "serious abnormality"
or "serious handicap'. Guidance to doctors is inadequate
and the profession is failing to regulate itself. While rigorous
definitions would help, Parliament should reconsider abortion
for foetal abnormality. The upper limit for abortion for disabled
babies should not be higher than that for able-bodied babies.
11-12. Demography—abortion
is partly responsible for fertility rate being well below population
replacement rate. Together with longevity there are significant
economic and care implications. Any change in the law that might
increase abortion totals should be resisted.
13-17. Relative risks—mortality
following abortion is higher than currently recognised. Much is
causally related and occurs regardless of the gestation at which
abortion is performed. The RCOG should update its guidance, women
should be counselled accordingly, and psychiatric indications
for abortion should be removed.
18-20. Two signatures—the
1967 Act never made abortion legal; it conferred upon doctors
a possible defence against illegality. The requirement for two
signatures reflects Parliament's medico-legal concerns, and should
remain.
21-24. Nurse/midwife abortions—medical
abortion is less safe than often assumed. Morbidity and mortality
are described. CMF agrees with the BMA there should be no extensions
of current practice.
25. Acute complications—those
reviewed by the RCOG are listed. They are usually obvious, short
term, and well managed by gynaecologists.
26-29. Subsequent pre-term delivery—there
is robust evidence that induced abortion increases risk of premature
birth in subsequent pregnancies. Such premature births cause neonatal
mortality and ongoing disability, with significant economic costs.
30-32. Mental health problems—there
is overwhelming recent evidence that abortion causes significant
rates of serious mental health problems. CMF calls for the RCPsych
urgently to review its published guidance.
33-34. Breast cancer—there
is some evidence suggesting that abortion is a significant risk
factor, and CMF believes women should be counselled accordingly.
35. Conclusion—we have summarised
the many scientific developments which cause concern for women,
but the ethical debate cannot be avoided.
CHRISTIAN MEDICAL
FELLOWSHIP'S
STATUS AND
RELEVANT CORE
BELIEFS
1. The Christian Medical Fellowship (CMF)
is an interdenominational Christian organisation with more than
4,500 British doctor members, practising in all branches of the
profession. Through the International Christian Medical and Dental
Association we are linked with like-minded colleagues in over
100 other countries.
2. CMF regularly makes submissions on ethical
and professional matters to Government committees and official
bodies. In January 2007 we responded to the House of Commons Science
and Technology Committee's Inquiry into Government Proposals for
the Regulation of Hybrid and Chimera Embryos. All submissions
are on our website at www.cmf.org.uk/ethics/submissions/.
3. One of CMF's aims is "to promote
Christian values, especially in bioethics and healthcare, among
doctors and medical students, in the church and in society".
We are very concerned at the large numbers of abortions performed
in the UK, but note that "the Committee will not be looking
at the ethical or moral issues associated with abortion time limits".
Whilst reluctantly restricting ourselves to the science in this
Submission we wish to emphasise that law cannot be divorced from
ethics and morality and that science must be undertaken within
an ethical framework.
THE CONSULTATION
4. We further regret the short time scale
for this consultation, over the summer holiday period, and question
how this vast subject can possibly be considered adequately when
"Submissions should be as brief as possible". In this
Submission we present summaries of key findings.
THE SCIENTIFIC
AND MEDICAL
EVIDENCE RELATING
TO THE
24-WEEK UPPER
TIME LIMIT
ON MOST
LEGAL ABORTIONS
Foetal viability
5. Since 1990 there have been many relevant
developments. Mortality and morbidity remain relatively high,
but survival has improved steadily year-on-year for extremely
preterm infants born at 24 weeks' gestation or less. Whilst the
widely quoted 1995 EPICURE study in the UK and Ireland showed
that average survival to discharge was only 11% for babies born
live at 23 weeks and 26% at 24 weeks,1 by contrast Hoekstra et
al's data published in 20042 for outcomes in a 15-year study of
infants born between 23 and 26 weeks" gestation at one US
specialist neonatal centre show a consistent year-on-year improvement.
Between 1996 and 2000 there was an overall survival rate of 66%
at 23 weeks and 81% at 24 weeks" gestation. At University
College London Hospital a prospective long-term follow-up study
has shown survival rates in 1996-2000 of 42% at 23 weeks and 72%
at 24 weeks.3.
6. Long-term follow-up shows a minority
of extremely preterm survivors have some neurodevelopmental impairment,
with significant disability identified in 15-20%. But by their
very nature, long-term outcome studies represent the outcome following
a now outdated standard of care—EPICURE tells us about infants
born in 1995. Obstetric and neonatal care are changing and improving
rapidly: in facilities, in training, and with more in-utero transfer
to major perinatal centres. After discharge there are more therapeutic
resources and better educational and behavioural care available.
For these reasons we should be careful using historical data when
considering children born in the present, and the future.
7. Because of these continuing improvements
in survival, CMF believes Parliament should review the 24-week
upper time limit.
Definition of "serious abnormality"
8. The Act provides for abortion to term
if "there is a substantial risk that if the child were born
it would suffer from physical or mental abnormalities as to be
seriously handicapped'. There is no definition of "abnormalities"
and Parliament has signalled its general concern about outcome
in the expression "seriously handicapped". This is not
defined either, and definitions have never come before the courts.
The BMA4 and the Royal College of Obstetricians and Gynaecologists5
have issued guidance on factors that should influence individual
decisions, including the probability of effective treatment, future
ability to communicate, the probable degree of dependence on others,
and the likely suffering of the child or their carers.
9. While we dispute the unnecessarily negative
views of disability and dependence implicit in parts of this guidance,
in practice we are concerned with the failure of the medical profession
to regulate itself in this area. In 2001 a 28 week foetus was
aborted for bilateral cleft lip and palate. There was public outrage.
The Crown Prosecution Service declined to prosecute the two doctors
involved, satisfied they had decided in good faith that the child,
if born, would be seriously handicapped.6 Other minor abnormalities
also reported to have resulted in termination include webbed fingers
and extra digits.7 Improvements in in-utero surgery, neonatal
intensive care, paediatric medicine and surgery, and educational
care and community support mean that many abnormalities are now
far less significant in the degree of handicap they cause. These
developments mean that Parliament should review the whole question
of abortion for foetal abnormality. Rigorous definitions would
aid that process.
10. CMF supports the disability lobby's
view that the upper limit for abortion for disabled babies should
not be higher than that for able-bodied babies.
MEDICAL, SCIENTIFIC
AND SOCIAL
RESEARCH RELEVANT
TO THE
IMPACT OF
SUGGESTED LAW
REFORMS ON
FIRST TRIMESTER
ABORTIONS
Demography
11. More than one in five of all pregnancies
in England ends in abortion.8 This contributes significantly to
the fact that total fertility rates are now well below the rate
needed for population replacement. Together with an increase in
longevity, this decline in the birth rate with consequent reduction
in the numbers of those of working age strains the funding of
pensions and National Insurance, and at current rates the problem
will worsen.
12. CMF is opposed to any change in the
law to facilitate first trimester abortions believing this would
lead to an increase in the total number of abortions. Should such
considerations take place in Parliament, we urge that the medium
and long term demographic implications are taken into account.
The relative risks of early abortion versus pregnancy
and delivery
13. The RCOG maintains that at any gestation
the risks to a mother of induced abortion are lower than continuing
the pregnancy to term.9 Many doctors therefore interpret the Act
so that any woman requesting an abortion is offered one because
continuing the pregnancy would pose a "greater risk to her
physical and mental health, than if she had an abortion".
14. This claim, based on the Confidential
Enquiry into Maternal Deaths, 10 is questionable because of under-reporting
of late deaths, the deliberate hiding by women of previous abortion,
and reluctance by some health professionals to explore possible
previous history of abortion.
15. "Linkage studies" are more
reliable. These identify women of child-bearing age who have died
and then explore their medical history from records. Two such
studies have been published. The Finnish study11 collected national
data on all women who died between 1987 and 1994 for one year
after abortion or delivery. Researchers found that compared to
women who delivered, those who had an abortion had increased mortality—from
both natural and unnatural causes. The "age-adjusted odds
ratio" is the number of times more likely that a woman of
a certain age after an abortion dies in a particular way than
if she kept her baby. Odds ratios were 1.63 for deaths from natural
causes, 4.24 for deaths from accidents, 6.46 for deaths from suicide,
and 13.97 for deaths from homicide. Relevant to the question of
facilitating first trimester abortion, the suicide rate was independent
of the gestation of abortion. 12 Avoiding late abortions would
therefore not affect the raised mortality from suicide.
16. The Californian study confirmed the
increased mortality associated with abortion, with broadly comparable
findings. 13 Whether these findings are causally or independently
associated with abortion is considered in Paragraph 30ff.
17. CMF holds that mortality and morbidity
following abortion, especially for psychiatric reasons, are higher
than currently recognised. Much of this mortality is causally
related to the abortion and occurs regardless of the gestation
at which abortion is performed. The RCOG should update its guidance,
women should be counselled accordingly, and psychiatric indications
for abortion should be removed.
The role played by the requirement for two doctors'
signatures
18. It is suggested the law be changed to
allow what would effectively be "abortion on demand"
in the first trimester, with the signature of only one doctor,
as per a consent form for any other operation. The recent discussion
has been entirely about practice, with claims that the current
requirement is unnecessarily obstructive and has caused potentially
dangerous delays.
19. However, the requirement for two signatures
is a medico-legal one which reflects Parliament's recognition
in 1967 (not altered in 1990) that any doctor facing a woman requesting
abortion has two patients to consider, and that it is being proposed
intentionally to end the life of the more vulnerable one. The
Act never made abortion legal; it conferred upon doctors a possible
defence against illegality. In the requirement for two signatures,
and as with cremation certificates, the two doctors are expected
to "police" each other. Properly performed, there would
be the incidental benefit of two opportunities for counselling.
20. That the profession at large has failed
in this, and that the process has often become a sham, is not
a reason for removing this provision from law.
The practicalities and safety of nurse/midwife
abortions
21. The proposal that nurses or midwives
should carry out abortions, and that the second stage of early
medical abortions could occur in patients' homes is essentially
a discussion about the safety of the medical abortion regime,
using two drugs, mifepristone (RU-486) and a prostaglandin, usually
misoprostol.
22. Medical abortion is not as safe as commonly
assumed and it is not always effective. Failed and incomplete
abortions require surgery. In trials, almost all women using mifepristone
for medical abortions experienced abdominal pain or uterine cramping;
and a significant number experienced nausea, vomiting, diarrhoea.
Vaginal bleeding or spotting lasts on average 9-16 days, while
up to 8% of patients bleed for 30 days or more. Pelvic inflammatory
disease occurs in about 1%.14 In a recent review, 15 complications
involving hospitalisation were more than twice as likely following
medical abortions than surgical ones: 1.5% after medical abortion
as opposed to 0.6%.
23. By early 2006, there had been at least
six deaths in North America as a result of taking mifepristone
plus misoprostol. Four US fatalities and the Canadian one resulted
from infections with Clostridium sordellii causing endometritis
and toxic shock syndrome. 16,17 In the UK, there have been two
possible deaths following medical abortion. 18 All the women who
died were young and previously healthy.
24. Abortion whether surgical or medical
always has potential risks to the woman. CMF agrees with the BMA
that there should be no extensions of current practice.
EVIDENCE OF
LONG-TERM
OR ACUTE
ADVERSE HEALTH
OUTCOMES FROM
ABORTION OR
FROM THE
RESTRICTION OF
ACCESS TO
ABORTION
Acute complications
25. The RCOG lists the major acute complications
of surgical abortion as haemorrhage, uterine perforation and rupture,
cervical trauma, failed abortion, and post-abortion infection.
19 These usually present obviously, are generally short term,
and are successfully managed by gynaecologists. Of more concern
are the following three long term complications, which generally
involve paediatricians, psychiatrists, and surgeons and oncologists.
Subsequent pre-term delivery
26. There have been many reputable studies
investigating the association between abortion and pre-term delivery.
Thorp et al's detailed 2003 review analysed results for 24 published
studies20 and reported that 12 found a positive association with
increased risk ratios which were consistently between 1.3 and
2.0. Seven published studies found a dose-response effect: the
risk estimate increased with increasing numbers of induced abortions.
27. Rooney and Calhoun's 2003 review21 showed
at least 49 studies had demonstrated a statistically significant
increased risk of premature birth or low birth weight following
an induced abortion. Again most studies showed a dose response
relationship. Only eight failed to show an increased risk of preterm
delivery, and none demonstrated any protective effect of previous
abortion.
28. This association, further supported
by two more recent European studies (EPIPAGE22 and EUROPOP), 23
is significant for health outcomes in subsequent pregnancies and
for their economic costs. Extremely preterm delivery is associated
with high risk of neonatal death and of permanent brain damage
causing long term disability. Approximately 50% of all abortions
in England and Wales are undertaken in women under 25, whereas
75% of all live births occur to mothers aged over 25. 24 Thus
most women considering abortion will subsequently deliver one
or more live children, who will face these risks. Women should
be adequately counselled about abortion and subsequent pregnancies.
29. Appreciation of this association is
a recent development, and must be given full consideration should
Parliament review abortion law.
Psychological and psychiatric consequences
30. Until recently, any association between
abortion and mental health problems was effectively dismissed
not as causal, but as incidental due to other confounders. But
since 2000, there has been much evidence from robust and methodologically
sound controlled studies that abortion does cause the following:
31. Increased psychiatric hospitalisation
(admission rates were higher post-abortion than post-partum when
those with a prior psychiatric history were excluded); 25 increased
psychiatric outpatient attendance (outpatient funding claims were
higher in the post-abortion group when prior psychological problems
were controlled); 26 increased substance abuse during subsequent
pregnancies carried to term (women who had aborted were significantly
more likely to abuse cannabis, other illicit drugs and alcohol
during a subsequent pregnancy); 27 increased death rates from
injury, suicide, and homicide (a controlled study in Finland 1987-2000);
28 and perhaps most relevant for UK comparison, a landmark 2006
New Zealand controlled population study29 showed higher rates
not due to prior vulnerability of major depression, suicidal ideation,
illicit drug dependence, and overall mental health problems.
32. There is also qualitative evidence from
women's accounts, but quantitative evidence that abortion causes
significant rates of serious mental health problems is now so
overwhelming that the American Psychological Association has removed
its guidance and is reviewing it. CMF calls on the Royal College
of Psychiatrists and the RCOG urgently to do likewise.
A possible link with breast cancer
33. Breast cancer rates have been rising
in Europe and North America for several decades and are projected
to rise further. 30 There is evidence suggesting that having an
abortion may increase a woman's risk of breast cancer in later
life. 31 A 1997 review that pooled 23 studies found that the risk
increased by 30%32 but authors of a 2001 review have denied a
link. 33 There are clearly powerful vested interests on both sides
of this debate and space precludes an in-depth review. However,
it is undisputed that a full term pregnancy protects against subsequent
breast cancer, and that significantly pre-term deliveries make
it more likely. The link is therefore biologically plausible.
34. CMF believes that it is prudent to acknowledge
that "the jury is out", advocates further research to
conclude the debate, and in the interests of informed consent
believes every woman considering abortion should be offered as
much information about the possible risks as she wishes.
CONCLUSION
35. CMF is grateful for this opportunity
to express its concerns about the recently realised risks to women
of induced abortion. We have confined ourselves to scientific
developments, but cannot end without a reminder that abortion
is always a procedure with a 50% mortality. The ethical debate
cannot be avoided. We wish the Committee well in their deliberations
and would like to give oral evidence.
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September 2007
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