Memorandum 36
Submission from the Council for Health
and Wholeness
1. INTRODUCTION
In this submission, we would like to focus on
the safety issues surrounding "medical abortions" and
home abortions.
We recognise that there are increasing efforts
to offer "consumer-friendly" abortion, for example "medical
abortions" which usually don't require a surgical intervention;
nurse-led abortions; and abortions at home.
We would like to express our serious concerns
about the physical, emotional, social and spiritual impact of
all types of induced abortion. While we are aware that this enquiry
is not focusing on the moral or ethical aspects of abortion, nevertheless
there is a need to recognise that there are serious ethical and
moral issues involved in the abortion debate.
2. CLINICAL REVIEW
2.1 Adverse psychological effects after abortion
While it is generally stated that abortions
are usually safe and have few, if any, adverse psychological effects,
recent research paints a different picture.
Recent evidence points to adverse psychological
effects after abortion, even in women with no previous psychological
problems. (Fergusson DM et al. Abortion in young women and subsequent
mental health. Journal of Child Psychology and Psychiatry 47:1
(2006), 16-24). This very important prospective longitudinal study
followed up 500 New Zealand girls and young women from the time
of their birth to 25 years of age. Each woman's mental health
was measured at age 16, 18, 21 and 25. The women who had had an
abortion experienced nearly twice the level of mental health problems
as those who had either given birth or never been pregnant. They
also had three times the risk of major depressive illness compared
to the other groups. These results were statistically significant
even after controlling for previous mental health, and persisted
across a series of ages.
We are aware of several recent review articles
on the issue of psychological adverse effects of abortion. Thorp
et al reviewed a number of studies up to 2002 which contained
more than 100 women per study, all followed up for more than 60
days. (Thorp, JM et al. Long-Term Physical and Psychological Health
Consequences of Induced Abortion: Review of the Evidence. Obstet
Gynecol Survey 2002; 58, 67-79.) Their summary states: "of
particular note is the association between induced abortion and
either suicide or suicide attempt.[231]
This is an objective rather than a subjective outcome, and because
the effects are seen after induced abortion rather than before
indicates either common risk factors for both choosing abortion
and attempting suicide, such as depression, or harmful effects
of induced abortion on mental health. This phenomena is not seen
after spontaneous abortion".[232]
2.2 Home abortions and nurse-led abortions
The discussion about "home abortions"
and/or "nurse-led abortions" is essentially a discussion
about the safety of the medical abortion regime, based on the
use of two drugs, mifepristone (RU-486) and a prostaglandin, usually
misoprostol.
2.3 Mifepristone (RU-486)
Mifepristone is a synthetic steroid that essentially
acts as anti-progesterone. Progesterone is the hormone that maintains
a pregnancy. In medical abortion, mifepristone blocks progesterone
receptors which leads to endometrial degeneration and softening
and dilatation of the cervix. Mifepristone reduces production
of the hormone HCG, which in turn causes decreased production
of progesterone. Following administration of mifepristone, a prostaglandin—misoprostol—is
given and this usually produces a medical abortion.
2.4 Medical Abortion
Royal College of Obstetricians and Gynaecologist
(RCOG) guidance (Royal College of Obstetricians and Gynaecologists.
The Care of Women Requesting Induced Abortion. September 2004)
recommends medical abortion using mifepristone plus prostaglandin
as the "most effective method of abortion at gestations of
less than 7 weeks" and describes medical abortion as an "appropriate
method for women in the 7-9 week gestation band". According
to the RCOG guidance, this method, however, can be used up to
24 weeks as it "has been shown to be safe and effective".
In medical abortions up to 9 weeks, a dose of
mifepristone orally is followed 1-3 days later by a dose of misoprostol
(a prostaglandin, that induces uterine contractions) vaginally.
If the pregnancy is beyond 9 weeks and up to 24 weeks, this regime
is then followed by up to four further doses of misoprostol, either
vaginally or orally.
2.5 Effectiveness of medical abortion
Medical abortion has a "success" rate
that ranges from 75-95%, with about 2-4% of failed abortions requiring
surgical abortion and about 5-10% of incomplete abortions (not
all tissue is expelled, requiring surgical intervention), depending
on the stage of gestation and the medical products used. (Trupin,
SR et al. Abortion on www.EmedicineHealth.com, June 2007)
2.6 Safety and side effects of medical abortion
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 an average of nine to sixteen
days, while up to 8% of patients bleed for 30 days or more. Pelvic
inflammatory disease (PID), a serious complication, occurred in
about 1%. Between 4.5 and 7.9% of women required surgical intervention
following medical termination for a variety of reasons, including
treatment of bleeding, incomplete expulsion of the pregnancy and
ongoing pregnancy after medical abortion. It is estimated that
medical abortions are 5 to 10 times as likely to "fail"
as surgical ones, therefore requiring surgical intervention in
a then-advanced pregnancy. (FDA-approved Data sheet on Mifepristone
[Mifeprex, Danco Laboratories], July 2005; www.fda.gov/cder/foi/label/2004/020687lbl—Revised.pdf)
In a recent review, complications involving
hospitalisation were at least twice as likely following medical
terminations than following surgical terminations: 1.5% of women
required hospitalisation after medical termination as opposed
to 0.6% after surgical termination (Goodyear-Smith F, First trimester
medical termination of pregnancy: an alternative for New Zealand
women. Aust N Z J Obstet Gynaecol. 2006 Jun;46(3):193-8.)
Teratogenic effects may result from the use
of prostaglandins, including misoprostol, in human beings. Skull
defects, cranial nerve palsies, delayed growth and psychomotor
development, facial malformation and limb defects have all been
reported after exposure during the first trimester of pregnancy.
(FDA-approved Data sheet on Mifepristone [Mifeprex, Danco Laboratories],
July 2005; www.fda.gov/cder/foi/label/2004/020687lbl—Revised.pdf).
2.7 Mortality due to medical abortion
By early 2006, at least 5 women had died in
North America (5 in US and 1 in Canada) as a result of taking
Mifepristone followed by misoprostol. In the UK, there have been
two possible cases of death following medical termination. (Ms
Rosie Winterton, Written Answer, House of Commons Hansard; 28
April 2004).
Four of the US fatalities and the Canadian fatality
resulted from infections with a virulent bacterium (Clostridium
sordellii). The cases have been described as deaths due to endometritis
and toxic shock syndrome associated with this bacterium that occurred
within one week after medically induced abortions. (Fischer M,
et al. Fatal toxic shock syndrome associated with Clostridium
sordellii after medical abortion. N Engl J Med. 2005;353:2352-60;
Sinave C, et al. Toxic shock syndrome due to Clostridium sordellii:
a dramatic postpartum and postabortion disease. Clin Infect Dis.
2002;35:1441-3.).
The disturbing features were that all the women
who died were young and healthy; they had apparently successful
terminations with no complications, the initial presentation of
the toxic shock syndrome were unspecific abdominal cramps, which
commonly occur after medical termination, and all women died within
5 days of administration of medication. All died less than 24
hours after hospital admission. Of note is that all five women
who died of infections had inserted misoprostol vaginally. It
is estimated that around half of medical abortions carried out
in the UK use vaginally administered misoprostol.
A recent review concludes that the risk of death
with medical termination, while low (1 in 100,000), is still 10
times greater than that with surgical abortion. (Creinin M, et
al. Mortality associated with mifepristone-misoprostol medical
abortion. MedGenMed. 2006;8:26.) As a result of these safety concerns,
a number of US doctors have been quoted as expressing serious
concerns about the safety of medical abortions and some have actually
stopped providing medical abortions altogether. (Some Doctors
Voice Worry Over Abortion Pills' Safety. New York Times; April
1, 2006)
There has been a case report of an adolescent
girl dying following self-administration of misoprostol in order
to induce abortion. (Henriques A, et al. Maternal death related
to misoprostol overdose. Obstet Gynecol. 2007;109:489-90)
2.8 Psychological effects of medical/home
abortions
Whereas there is no specific evidence on the
psychological effects of home or medical abortions it is worth
noting that the propensity for this type of abortion to induce
psychological sequelae is not insignificant. For this method of
abortion the woman usually has to take the abortifacient medication
herself and/or has to insert a pessary into her vagina, thereby
procuring the abortion herself. While with a surgical abortion
it is easier to "blame the doctors" for what happened,
with a medical abortion this is not so easily done.
2.9 Anecdotal experience
While some surveys describe similar satisfaction
with medical as with surgical abortions, there is some anecdotal
evidence that medical abortions can be very traumatic:
I have been through a medical termination at
five weeks, and it was the most traumatic event of my life. Whilst
I wholeheartedly agree with a woman's right to have a termination,
I would hate to see this made available at home. It's not an easy
thing to go through. Anon, UK (Should home abortions be allowed?
http://news.bbc.co.uk/1/hi/talking—point/3025318.stm)
There are a number of women who have had both
a medical and surgical termination. While there are those who
appear to prefer the medical termination, there are also women
who found medical terminations very distressing as it is essentially
like "having a baby":
Anne Hawkins, 36, also of New York, said she,
too, had had both pill-based and surgical abortions. But taking
RU-486, she said, "was the worst experience, the most physically
and emotionally painful thing, that I've ever been through."
Ms. Hawkins had another abortion in March, and she chose surgery.
"It was 10 minutes, max, and then it was over". Ms Hawkins
said of the surgical procedure. "The pill for me was the
experience of having a baby. Contractions for 10 hours, sweating,
screaming, being by myself. It was emotionally scarring and physically
horrible". (New York Times, May 11, 2006)
2.10 Black Market
An important consideration needs to be given
to the possibility of the drugs used for medial abortions being
available on the black market and/or sold over the internet. There
is evidence for a thriving black market for mifepristone and/or
misoprostol in Brazil, China and the US. (US embassy in Beijing
report; November 2000; Misago C, et al. Determinants of abortion
among women admitted to hospitals in Fortaleza, North Eastern
Brazil. Int J Epidemiol. 1998;27:833-9; The New York Times, October
2, 2005.) The FDA recently issued a warning not to buy mifepristone
over the internet. Please note that the black market is not limited
to countries which have restrictive abortion laws, but also occur
where abortion has been legalised, such as in the US and China.
With the proposed increase in availability for medical abortions,
it is very likely that there will be an increase in the black
market for the drugs used, with all the adverse consequences.
3. SUMMARY OF
CONCERNS
3.1 To propose "home abortions"
and extend the availability of nurse-led abortions essentially
constitutes an attempt to normalise abortion, to increase the
availability of abortion and to downplay any concerns about this
procedure.
3.2 The advisability of medical abortions
being carried out as early in pregnancy as possible leaves little
time for a proper, balanced consideration of whether abortion
is the right course of action. This is more likely to result in
a pressurised decision to abort a pregnancy with possible later
regret.
3.3 Abortions, whether carried out at home
or performed in a hospital setting, have serious adverse physical,
emotional and spiritual consequences.
3.4 There is increasing robust evidence
linking abortion to adverse psychological effects. A 25-year longitudinal
study found that women who had an abortion experienced nearly
twice the level of mental health problems and three times the
risk of major depressive illness compared to those who had either
given birth or never been pregnant, even after correction of confounding
factors.
3.5 Medical abortion is not as safe as perhaps
commonly assumed. Medical abortion has ten times the mortality
of surgical abortion. There have been at least five deaths in
North America following medical abortion using mifepristone (RU-486)
and a prostaglandin, usually misoprostol. The women who died in
North America following medical abortion using mifepristone died
through a rapidly progressing condition due to an infection with
Clostridium sordellii.
3.6 Although it is stated that the Committee
will not be looking at the ethical or moral issues associated
with abortion time limits, we would strongly urge the Committee
to consider moral and ethical questions about abortion as an increasingly
used method of birth control, not least as they come into quite
sharp focus when considering medical abortions and home abortions.
If there is a moral wrong committed through abortion—and
it is probably correct to state that a very large proportion of
the population, while perhaps not condemning abortion, have a
degree of unease about abortions—then this is made more
acute through home abortions and medical abortions.
3.7 There can be no disagreement that abortion
involves the deliberate taking of a life. This inevitably raises
questions such as: Under which circumstances can the taking of
a life be "right"? Would it be acceptable to take away
the life of an unborn child because of poverty or poor housing
situation? Would it be acceptable to take away a life because
the mother already has too many children or there are serious
relationship issues? Would it be acceptable to take away the life
of an unborn child because it might be handicapped or because
it was conceived through rape? Would it be acceptable to take
away the life of an unborn child because the pregnancy itself
endangers the life of the mother?
3.8 We do not purport to present universally
acceptable answers to these questions; however, our standpoint
is based on the Judeo-Christian tradition, which have been foundational
to British society for generations and which emphasises the sanctity
of all life, irrespective of circumstances and irrespective of
whether a child may or may not be disabled. The ambiguity surrounding
statements about the "status" of the unborn child needs
to be addressed when considering the serious matter of abortion.
At what stage of pregnancy does a foetus become a child with value?
Does the child born prematurely at 23 weeks gestation have a greater
right to medical help to live than the child aborted, for whatever
reason, at the same gestational age? Irrespective of one's moral
or ethical stance, the "Golden Rule" states "treat
others as you would like to be treated". Using the Golden
Rule, the concept of abortion becomes morally and ethically questionable.
3.9 We are seriously concerned about the
implications of "home abortions" and remain firmly opposed
to an extension of abortion availability through either "home
abortions" or increased nurse-led abortions.
September 2007
231 The following studies are quoted in this section
by Thorp:
— Hunton R, Bates D. Medium term complications after termination of pregnancy. Aust NZ J Obstet Gynaecol 1981;21:99-102.
— Gissler M, et al. Suicides after pregnancy in Finland, 1987-94: Register linkage study. BMJ; 1996;313:1431-1434
— Morgan C, et al. Suicides after pregnancy (Letter). BMJ 1997;314:902.
— Coleman PK, et al. State-funded abortions versus deliveries: A comparison of outpatient mental health claims over 4 years. Am J Orthopsychiatry 2002;72: 141-52.
— Reardon DC, et al. Deaths associated with pregnancy outcome: A linkage based study of low income women. South Med J 2002;95:834-841.
— Gilchrist A, Hannaford P, Frank P et al. Termination of pregnancy and psychiatric morbidity. Br J Psychiatry 1995;167: 243-248.
— Reardon D, Ney P. Abortion and subsequent substance abuse. Am J Drug Alcohol Abuse 2000;26:61-75.
. Back
232
Major B, et al. Psychological responses of women after first-trimester
abortion. Arch Gen Psychiatry 2000;57:777-784. Back
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