House of Commons - Science and Technology

Select Committee on Science and Technology Written Evidence

Memorandum 41

Submission from the Society for the Protection of Unborn Children

INTRODUCTORY COMMENTS

1. The Society for the Protection of Unborn Children (SPUC) welcomes an evidence-based approach by the Committee for its inquiry into "Scientific Developments Relating to the Abortion Act 1967" particularly with regard to the effect of abortion on women's health and to new scientific evidence relating to the foetus.

2. SPUC notes that the Committee is choosing not to address the very substantial moral and ethical questions associated with abortion time limits, but welcomes its consideration of important issues associated with the scientific evidence in each of the other aspects of its inquiry.

DEVELOPMENTS IN MEDICAL INTERVENTIONS AND EXAMINATION TECHNIQUES THAT MAY INFORM DEFINITIONS OF FOETAL VIABILITY—1(A)

3. If foetal viability determined the acceptability of abortion then the restoration of the pre-1990 situation would be demanded so that the baby's viability was a restraining factor. Well before 1990, some babies survived prior to 24 weeks, and the effect of specifying that time limit and eliminating viability as a consideration was to ensure that viable babies up to 24 weeks could be killed in utero under any grounds in the Abortion Act. However, any decision to permit or prohibit abortion based on time limits is fundamentally a decision based on ethical considerations, not scientific or medical ones.

4. The question of foetal sentience has been considered by some to inform the choice of time limits for abortion. While this is a much debated question, the probability that the foetus will experience pain during an abortion has led the RCOG to recommend foetal anaesthesia at least for very late abortions. Such guidance underlines the poor situation of the human foetus in comparison with say laboratory animals or livestock.

SCIENTIFIC OR MEDICAL DEFINITION OF SERIOUS ABNORMALITY—1(B)

5. Science and medicine are able to identify, define and categorise a wide range of disabilities, from those that are minor to those that are life threatening. With advances in genetics over recent decades, it is more rather than less difficult to define the parameters of disability. For example, genes that confer predispositions for serious illnesses that may occur early or late in life are making it possible to identify yet-to-be-expressed disability. This knowledge will likely create more difficult decision-making with regard to abortion. The question of what constitutes a serious abnormality will always remain an ethical one, for a value judgement of some type or another will have to be applied. And in the context of abortion this means a value judgement about whether certain lives are worth living.

6. It is SPUC's conviction that no human life, in utero or otherwise, should be judged inferior according to the level of disability, or by comparison with what is considered "normal". Judgements made about the value of disabled human life in utero have serious implications for how other people with disabilities are valued in our community. In any case, it is worth noting that the majority of people with disabilities acquired them after birth as a result of accidents, so terminating the lives of disabled foetuses cannot address the "problem" of disability.

7. If 1(b) is being raised as a result of perceived lack of access to abortion by parents of children with disability, then SPUC would like to raise the equally significant matter of the social and financial pressures on families caring for children with disabilities. It is extremely important to ensure that social services exist such that there is no pressure for abortion placed on parents whose unborn child is diagnosed with a disability.

RELATIVE RISKS OF EARLY ABORTION VERSUS PREGNANCY AND DELIVERY—2(A)

8. SPUC is aware that a large body of literature exists with regard to 2(a). However, an important point needs to be made about comparisons between surgical abortion and medical abortion using RU486. Comparisons have been made that suggest equivalence between the risks of surgical and medical abortion; however, an accurate comparison must correctly compare data at similar gestations, since abortions using RU486 typically occur in the first trimester. When this is done, medical abortions are significantly riskier than surgical ones. For example, quoted mortality figures suggest a 10-fold increase in mortality for RU-486 medical abortion as compared with surgical abortion for similar gestational age. [289]

ROLE PLAYED BY THE REQUIREMENT FOR TWO DOCTORS SIGNATURES—2(B)

9. If the reason for consideration of 2(b) is that there is widespread disregard for this requirement (that is, pre-signed blank forms, or doctors willing to sign without assessing the woman's situation) then we would argue that abuse of the law is not grounds, in and of itself, to relax the law. Reducing the already much-abused curbs on abortion will lead to more abortions, including more abortions on women who choose abortion because of adverse pressures or the hostility of other people to their pregnancy. Our impression is that woman very rarely want abortions, but many have abortions because of such external constraints.

10. If the reason for 2(b) is that fewer doctors either want to carry out abortions or even want to participate in any way, then it is inappropriate to relax the requirement for two doctors' signatures to circumvent the reality that abortion itself is problematic for many doctors. There have over many years been attempts to make doctors act contrary to their conscience by requiring them to refer a patient to another doctor who has no conscientious objection to abortion. [290]For a medical practitioner who conscientiously objects to a practice, the requirement to refer a patient to another practitioner who does not conscientiously object was recently recognised by the Joint Committee on Human Rights (12th Report, 2003-04 session) as constituting a breach of Article 9(1) of the European Convention on Human Rights. [291]The Joint Committee rightly recognises that referral that will lead to the provision of an abortion represents "participation in abortion". That is, such referral constitutes an unacceptable degree of cooperation in an abortion by making an essential contribution in the chain of events culminating in the abortion. [292]For those who conscientiously object to abortion, demanding that they make a referral like this is unfair and unreasonable.

11. If another reason for 2(b) is that some feel it is offensive and patronising for women to seek two doctors' signatures, it is important to note that this requirement reflects the distinct nature of abortion among medical procedures—to begin with, it is most typically performed on healthy women and foetuses. It has no proven therapeutic benefits. In addition, in the public conscience there is recognition of the unique position held by abortion. For example, research in Britain in 2006 found that 65% of women said the "woman's right to choose" should always outweigh the rights of the unborn. However, 55% of women thought that the overall number of abortions should be reduced. 85% felt that more support should be directed to help women to keep their babies as opposed to 8% who wanted access to abortion made easier. [293]Public misunderstanding of abortion practice was highlighted by the fact that more than two-thirds of women (68%) thought that disability in the baby was one of the most common reasons for abortion.

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(C)

12. SPUC is concerned that 2(c) may be more related to financial and time considerations (and conscientious objection on the part of doctors) and, if implemented, act at the expense of women's health and wellbeing. Both on the grounds of medical competency and accountability, SPUC considers the proposal to allow nurses or midwives to conduct abortions to constitute a risk to women's health.

EVIDENCE OF LONG-TERM OR ACUTE ADVERSE HEALTH OUTCOMES FROM ABORTION OR FROM THE RESTRICTION OF ACCESS TO ABORTION—3

13. SPUC hopes that the Committee will take into account the distinction between early and later abortion when considering the effects on women's health and wellbeing, as the research on women's health is quite distinctly divided according to gestational age, and the experiences of women differ according to gestational age—see below.

14. SPUC notes that no meaningful answer to point 3 is possible. It requires comparing women who obtain an abortion with women who sought one but were unable to obtain it. Such research would be unacceptable both to those who believe in "a woman's right" and those who recognise abortion as a homicide. In most countries where good data are available, most women are able to obtain abortions. Historical comparisons are useful to a small degree, but the social, economic, cultural and health circumstances will render data non-comparable.

15. Comparisons of developed nations where abortion is widely available with developing nations where abortion is not widely available are unreliable, particularly because of significant differences in general healthcare, sanitation and living standards. Claims are often made that restricting abortion results in poorer maternal health outcomes, higher maternal and child mortality and so forth. These outcomes are confounded by the non-comparable contexts in terms of social, medical and financial resources available to families. These claims also tend to rest on the assumptions that abortion can be performed with similar mortality and morbidity rates in the developing world as in western clinics and hospitals, and that women with poor outcomes, large families, poor finances and poor health would have sought abortion if available. The evidence for these assumptions is lacking, and the latter assumption is likely in itself to be deeply offensive to these women.

THE IMPORTANCE OF PRE-ABORTION FACTORS IN LONG-TERM OR ACUTE ADVERSE HEALTH OUTCOMES OF ABORTION FOR WOMEN—3

16. Motivating factors underlying abortion decisions are important because they sometimes increase the risk of certain post-abortion outcomes, specifically mental health ones. For example, if a woman is motivated to have an abortion because of foetal disability, her risk of psychological harm is heightened. [294]

17. A decision to have an abortion is more complex than simply not intending to become pregnant. [295]Whilst some women are motivated to seek abortions because of incest, rape, fetal abnormality or maternal health, these represent a small percentage of total abortions. [296]In the majority of cases the factors that motivate women to consider abortion include relationship problems, pressure from partners and family members, study and career aspirations, financial difficulties, lack of confidence as a mother, and lack of community support. [297]It is also possible that the perceived public acceptance of abortion could contribute to a decision to abort. An equally potent idea is a perceived public disapproval of some women becoming mothers (eg young, poor, or disabled women)—this may influence a woman's decision, especially if she has little support from family and friends to continue with her pregnancy, even if she wants to.

18. Adverse health outcomes for women may also result from the known strong association between abortion and domestic violence and the abuse of women. [298]Furthermore, because depression and depressed mood are common in pregnancy, they may contribute to an abortion decision. [299]

19. With a major decision such as abortion, it is not surprising that ambivalence is common. [300]What is of particular concern is the relationship between ambivalence and the development of long-term post-abortion psychological distress. [301]

20. Two other risk factors for later psychological distress are moral opposition to abortion and abortion for foetal disability. Women sometimes have abortions despite being morally opposed to them, [302]which suggests the presence of strong coercive influences towards abortion. There are more negative post-abortion effects when women are morally opposed to abortion. [303]Abortions for foetal disability or disease lead to more severe consequences not only for the woman but also for her partner. Numerous studies have identified a high incidence of negative emotions, [304]psychological distress, [305]post-traumatic symptoms[306] and somatic complaints. [307]

PHYSICAL EFFECTS OF ABORTION

21. Risk of death resulting directly from complications during abortion is rare; however, when deaths from all causes are examined in the first year following an abortion, several studies have identified an increased risk compared either to giving birth or never being pregnant. Causality has not been confirmed,[308] ,[309] ,[310] but various explanations may be considered. Women who have abortions may already take more risks or care less for their health. Alternatively, they may experience stress after an abortion that is linked to it. [311]

22. There is an increased risk of premature delivery[312] and very premature delivery[313] in future pregnancies among women who have had abortions.

23. Infection can result from abortion, leading to an increased risk of infertility. [314]This risk is particularly relevant where there is a pre-existing genital infection. [315]This is often dismissed as being unrelated to the abortion procedure, but clearly the procedure can facilitate the spread of infection in the reproductive system.

24. Abortion is a risk factor for later miscarriage.[316],[317]

25. Although the risk is slight, abortion increases the risk of uterine perforation during subsequent abortions. [318]

26. Previous abortion is a risk factor for placenta praevia, [319]although not when the method used is vacuum aspiration. [320]

27. Abortion may confer a risk for low birth weight in later pregnancies, [321]although this association may be weak. [322]

28. Whether breast cancer risk is elevated by abortion is a controversial question that has been the subject of numerous studies, several showing increased risk[323],[324] ,[325] and some showing none. [326]However, it is well established that carrying a first pregnancy to birth is protective against breast cancer. [327]

29. Abortion using RU486 is associated with specific contraindications as well as physical risks including haemorrhage, pain, insomnia, vaginal bleeding, abdominal cramping, nausea, vomiting, diarrhoea, headache, muscle weakness, dizziness, fatigue, viral infections, fever, chills, backache, difficulty in breathing, rise in temperature and fall in blood pressure. [328]

PSYCHOLOGICAL EFFECTS OF ABORTION

30. Mild, moderate or severe psychological harm can result from abortion. A general consensus among researchers about post-abortion effects is that between 10% and 20% of women will experience severe negative psychological complications. [329]Women not falling within this category may nevertheless experience emotional distress even after having experienced the relief that is a common short-term response to abortion. [330]

31. Results from a 2006 New Zealand study[331] on mental health and abortion confirm other work showing a link between the two. [332]The New Zealand study revealed that 42% of women who had an abortion also experienced major depression in the last four years. This is nearly twice the rate of those who had never been pregnant and 35% higher than those who had continued their pregnancy. This study also showed that abortion increased the risk of anxiety disorders.

32. A small proportion of women develop post-traumatic stress disorder following abortion, [333],[334] Studies indicate that this may be related to cultural factors. [335]

33. Several studies have identified other psychiatric complications following abortion, and therefore women who have an abortion are at higher risk of psychiatric admission compared with women who carried to term. [336]In a major Californian study, women who had an abortion were over-represented in treatment categories that included bipolar disorder, neurotic depression and schizophrenic disorders. [337]Nevertheless, a major UK study did not identify a difference in total psychiatric disorders between aborting women and those who carried to term. [338]

34. The same study did however identify an increase in deliberate self-harm, which includes substance abuse. [339]Among women whose first pregnancy was unintended, those who had an abortion were at greater risk of substance abuse compared with those who carried their unintended pregnancy to term. [340]When pregnancy was assessed in relation to past perinatal loss—that included abortion, stillbirth and miscarriage—only abortion was found to be associated with an increased risk of substance abuse during that pregnancy. [341]

35. A range of other negative emotional responses have been identified following abortion. These include sadness, loneliness, shame, guilt, grief, doubt and regret.[342],[343] ,[344] Among US college students—women who had an abortion and men whose partners had an abortion—one third of women and one third of men were uncomfortable and expressed regret about the abortion decision. [345]A third of men and women also experienced a sense of longing for the aborted foetus. Moreover, they often use terms like "child" or "baby" to describe their loss.

36. Some evidence exists for a "replacement pregnancy" phenomenon, where a subsequent pregnancy may be seen as a way of resolving grief and stress about an abortion. [346]

THE SPECIAL CASE OF ABORTION FOR FOETAL ABNORMALITY

37. There is a solid body of evidence showing that when an abortion is undertaken for reasons of foetal abnormality the after effects can be particularly traumatic. Strong and persisting grief is likely, similar to that experienced for a stillbirth, but with the additional factor that the abortion was chosen.[347],[348] ,[349] In a major Scottish study, a majority of men and women experienced negative emotional responses and somatic complaints, including problems in their sexual relationships. [350]Among women, 40% experienced coping problems lasting more than 12 months. The effects can last much longer. For example, Dutch researchers found that grief and post-traumatic symptoms remained between two and seven years after the event. [351]Other researchers found that, contrary to expectations, traumatic stress at 4 years was not significantly different to that experienced at 14 days. [352]

38. The assumption that early detection and termination for foetal anomaly leads to better psychological outcomes for women is being questioned. [353]

THE TERMS OF THIS INQURY

39. SPUC is concerned that the terms of this inquiry attempt an unsatisfactory separation of ethical and moral issues from scientific and medical evidence. For example, there is a contradiction between the committee statement that it "will not be looking at the ethical or moral issues associated with abortion time limits", yet requesting information on "whether a scientific or medical definition of serious abnormality is required or desirable in respect of abortion allowed beyond 24 weeks". The latter is a question about ethics.

September 2007