Select Committee on Science and Technology Written Evidence

Memorandum 42

Submission from Marie Stopes International

  Marie Stopes International (MSI) is the UK's largest provider of abortion services outside the NHS, seeing over one third of all cases in England and Wales each year. The organisation operates on a not-for-profit basis and supports a Global Partnership currently working in 39 countries across the developing world to provide sexual and reproductive healthcare services to approximately 4.5 million people every year.


  Key points:

    —  Many women seeking abortion close to 24 weeks find themselves in exceptionally difficult circumstances and almost half are teenagers,

    —  Further reduction of the upper time limit would constitute a huge source of distress for thousands of women every year and risk creating demand for illegal abortion,

    —  A significant reduction in the number of late second-trimester abortions could be achieved by improving the referral process and information for women including teenagers.

  Many women who come to Marie Stopes clinics at 20-24 weeks gestation have been affected by extreme personal circumstances and are determined not to continue their pregnancy. We perceive this to be an indication that reducing the time limit below 24 weeks would create demand for illegal and self-induced abortions.

  A reduction in the gestational time limit would affect many hundreds of British women every year: 3,000 abortions were induced between 19 and 24 weeks gestation in 2006. But the fact that these represent only 1.5% of the total 201,173 induced abortions in 2006 reflects MSI research findings that women who seek abortions late in the second trimester are often affected by extreme personal circumstances: 40% of the late procedures are accounted for by teenagers and a significant number of women appear to be affected by delays and inefficiencies in the referral procedure. [354]

  MSI has conducted interview-based research into the reasons why women seek late abortion. [355]The findings reveal that many such women feel themselves to be emotionally or physically unable to complete pregnancy. A vast majority of interviewees felt that the 24 week limit should be left intact and spoke of the emotional trauma and despair they would face had they been unable to access services. Some explained that the desperation might even have driven them to suicide. The study found that the situations that lead to late abortion usually fall into the following categories, with many women being influenced by more than one:

    —  Some women—often teenagers—went into denial about their pregnancy, leading to late presentation,

    —  A major change in personal circumstances, for example domestic violence,

    —  Delays in the referral process,

    —  Financial implications including for the ability to raise existing children,

    —  The signs or symptoms of pregnancy were not recognised until very late, making late abortion an inevitability rather than a conscious choice.

  Having reduced the time limit on abortion from 28 to 24 weeks, the HFE Act of 1990 has already placed considerable pressure upon women who do not realise they need an abortion until the second trimester. For women who are not diagnosed until late in the second trimester, the existing 24-week limit can mean they must decide whether or not to have a baby within days. Not only can this be a cause of great distress it can also lead to the "knee-jerk reaction" of seeking an abortion where, had more time been available, a woman may have decided she was in fact willing and able to have a child. The pressure is felt because:

    (a)  Women tend to need longer to decide whether to have an abortion in the second trimester because it is perceived as a more difficult decision to make;

    (b)  It usually takes longer to arrange an abortion procedure for a women in the second trimester.

  Many women will simply be unaware of their pregnancy until the second trimester. The earliest stage at which a woman can "feel" a pregnancy in the womb is 16 weeks. This means that some women will attribute the symptoms of pregnancy—mainly the lack of menses—to other causes such as contraceptives, breastfeeding, menopause or stress, or may not know the symptoms of pregnancy. Some—particularly teenagers—may go into denial about their pregnancy, hoping it will go away or refusing to believe the symptoms. Teenagers are also more likely to want to hide the pregnancy from their parents or simply take no action due to uncertainty about what to do.

  The time it takes to arrange an abortion in the second trimester means that any further reduction below 24 weeks would create situations for women where they request an abortion prior to the limit, but find that a procedure cannot be arranged within the time remaining. A recent University of Southampton study of women who had obtained an abortion in the second-trimester found that confusion among GPs about the referral process was a common source of delay, affecting 23% of the women sampled. [356]"GPs making it difficult" was another reason reported. These delays were found to be responsible for postponing the date of the abortion procedure by up to four weeks, pushing a number of women close to the 24 week limit. This makes the gestation later and hence the procedure is more difficult, with higher risk of complication and fewer providers available who can provide it.

  These inefficiencies point to a need for improving the referral service. The key methods of doing so are; promoting greater clarity among GPs of the referral process and removing the need for two doctors" signatures. Tightening the RCOG minimum standard for time between initial referral and the procedure from three weeks to two weeks would also have an impact. Such measures would create pressure for improvements in the provision of second trimester abortion services, which would in turn lead to a significant reduction in the need for late second trimester abortion.

  The attempt to make foetal viability an issue relating to the 24-week limit is misleading and misguided. The EPICURE study, which followed the outcome of 241 babies born at 23 weeks, found only 11% (26 babies) survived and only 3% survived with either no disability or only a minor disability. [357]Positive outcomes for premature births at this stage of gestation are extremely rare and should not jeopardise access to abortion. Given the continuing need for safe abortion services right up to 24 weeks, it is inappropriate to use such a contentious definition of foetal viability as a proxy for determining the time limit on abortions.

Our position

  MSI insists that the 24 week limit must be maintained. Lowering the upper time limit would not reduce the need for late abortion and therefore risks creating demand for unlicensed and unsafe abortion.

  The best means of reducing the incidence of 20-24 week abortions include:

    —  Improving access to information, for women and teenagers, on the signs and symptoms of pregnancy, on the side effects of different contraceptive methods and on the return to fertility;

    —  Improving access to earlier abortion, particularly in the second trimester, by reducing delays in referral. Means of doing so include:

      —  Improving information for GPs on the referral system and local abortion providers,

      —  Removing the need for two doctors" signatures and guideline for those who object to abortion (see below),

      —  A tightening of the RCOG minimum standards so that no woman has to wait longer than two weeks between the time of her initial referral and the abortion procedure.


  Key points:

    —  The requirement for two doctors' signatures is perfunctory and sometimes impedes access to abortion,

    —  The personal beliefs of some GPs can jeopardise access to abortion,

    —  Removing the need for two signatures, improving awareness among GPs of the referral system and clear rules for GPs who conscientiously object, would all contribute to reducing gestation lengths of induced abortion.

  The UK Abortion Act permits abortion where the continuance of pregnancy constitutes a greater health risk than if pregnancy were terminated. The fact that this is true of all pregnancies means that the Act legitimises abortion in all cases up to the 24 weeks ceiling. The greater health risk of pregnancy is illustrated here by UK figures where the proportion of maternal deaths in the 2000-2002 triennium vastly exceeds the proportion of deaths from legal abortion: [358]

    —  The maternal mortality rate was 13.1 deaths per 100,000 maternities.

    —  We calculate a "legal-abortion mortality rate" of 0.5 deaths per 100,000 legal abortions—three women died from the 568,800 legal abortions performed in the triennium.

  Yet the stipulation that a woman must acquire two doctors' signatures means that Great Britain is now one of the few countries in Europe where legislation grants doctors the power to determine whether a woman can have an abortion in her first trimester. Necessary in 1967 to make what was then seen as a controversial bill appear less radical, there is no longer a need for the two signatures. It places UK legislation behind countries including Italy, Germany and the Czech Republic in terms of recognising a woman's right to choose. It can also impede access to abortion.

  The legal requirement for two signatures effectively means that a woman's ability to access abortion is contingent upon her GP's own moral opinion. An MSI survey of 8,000 GPs found that 18%—almost one in five—were morally opposed to abortion. [359]Furthermore, 5% were both anti-abortion and also of the opinion that that a GP has no duty to inform a woman seeking abortion of their moral opposition. This implies that, of the UK's 35,000 registered GPs, 1,680 may be willing to obstruct a woman's access to safe abortion due to their own personal beliefs. The inequality this creates, where some women have more difficulty accessing abortion services than the more fortunate majority of women in the UK, is unjustified and unacceptable. Clear rules are needed for GPs to declare their conscientious objection and to refer a woman on to an appropriate source of professional help.

  The opposition of some GPs to abortion compounds inefficiencies in the referral procedure discussed in the previous section. Removing the need for doctors' signatures, together with other improvements in the referral procedure, would significantly reduce the number and proportion of abortions late in the second trimester.

Our Position

  MSI recommends:

    —  Removing the need for doctors' signatures,

    —  Clear rules for GPs who oppose abortion to declare their conscientious objection and refer women on to an appropriate source of professional help.


  Key points:

    —  MSI supports the principle of paramedical abortion but we note a number of important qualifications,

    —  Nurses or midwives providing abortion should do so only under supervision of a doctor,

    —  Providing choice over abortion procedure is a key component of quality service,

    —  Providing telephone support services is also an integral part of the abortion service

  MSI perceives neither surgical nor medical abortion procedure to be too complex for nurses to perform if given appropriate training and supports the principle of paramedical abortion. Trials by MSI in South Africa and Vietnam of almost 3,000 manual vacuum aspiration (MVA) procedures found that first trimester abortions performed by appropriately trained health professionals who are not doctors do not suffer from increased incidence of complication. [360]MVA is a simple procedure, comparable in its level of complexity to the insertion of IUD and to endoscopy. We note that the introduction of nurse endoscopy specialists is widely held to have improved efficiency and recognise the contribution nurses now make in delivering family planning services.

  However, abortion procedures differ from IUD insertion and endoscopy in the potential consequences when things go wrong. Given the paramount importance of minimising deaths from abortion, nurses providing surgical abortion should do so only under the supervision of a fully qualified doctor.

  Furthermore, MSI stresses the need to continue offering women choice over abortion procedure. The fact that many women choose surgical abortion means that any introduction of sites offering only medical abortion would constitute an unnecessary decline in the existing quality of service. It is important that any move to paramedicalise abortion should ensure that nurses are trained and able to provide both medical and surgical abortion in order to protect women's choice of procedure.

  Finally, symptoms of bleeding and cramping can be alarming for many women and, in rare cases, treatment for prolonged bleeding or haemorrhage may be required. Access to professional medical advice is therefore an integral part of the abortion service. It is essential that the provision of abortion procedures—medical or surgical—should be accompanied by requisite helpline services. MSI finds that just over half of our clients will contact the clinic by telephone for advice and reassurance.

  The importance of this consideration is further intensified by the potential to enable women to complete medical abortion at home. Given the low level of risk involved in medical abortion, MSI does not perceive a need for women to be present at a clinic or hospital when taking misoprostol. Nevertheless, for the reasons mentioned above, women taking misoprostol at home require access to support services by telephone. About 75% of clients who choose medical abortion from MSI subsequently phone for support from our call centre.

Our Position

  There are likely to be efficiency gains from enabling nurses and midwives to perform abortions. But the NHS would also need to ensure that it can provide:

    (a)  Choice of procedure to clients,

    (b)  Requisite helpline support,

    (c)  Doctor supervision for all surgical abortions.


  One of the findings from the MSI research into GPs' attitudes to abortion is that a greater proportion of younger doctors oppose abortion than the proportion of those with experience of life prior to the 1967 Abortion Act. [361]It is not hard to deduce that it is the experience of treating patients for the consequences of unsafe abortion—or lack thereof—that lies behind this outcome.

  MSI operates in 39 developing countries where access to abortion is often limited and even illegal under many circumstances. As providers of post-abortion care, we are acutely aware of the dangerous lengths that women in desperate circumstances will go to in order to end their pregnancy. Methods of self-induced abortion include drinking poisonous substances or dangerous quantities of alcohol, pushing substances (eg soap or bleach) into the uterus, inserting sticks, coat hangars and other sharp objects into the uterus, and severe pelvic pummelling. Women who abort in this way are likely to suffer incomplete abortion leading to septicaemia, infection, severe bleeding, infertility, psychological damage and death. Worldwide, one woman dies every eight minutes from an unsafe abortion and some 5.3 million women suffer temporary or permanent disability every year. [362]Prior to 1967, British women added to these figures.

  We reiterate the importance of upholding the 24-week time limit and of removing unnecessary obstacles to abortion, which include the need for doctors" signatures, lack of clarity among GPs as to the referral process, and the moral objections of a possibly growing minority of GPs.


  1.  The 24 week time limit should not be further reduced. Reductions would; jeopardise women in the often exceptional circumstances that lead to late abortion; put undue pressure on women to decide; and risk creating demand for illegal abortion.

  2.  Existing abortion legislation should be reviewed and brought up to date with other European countries, many of which provide termination of pregnancies at the woman's request in the first trimester.

  3.  The referral procedure for obtaining abortions in the second trimester needs to be improved and simplified; removing the need for doctors' signatures and ensuring that all GPs are fully informed on the referral procedure.

  4.  GPs opposed to abortion should be required to declare their conscientious objection when approached by someone seeking abortion and to follow clear rules on referring a woman to someone who can help.

  5.  While nurses and midwives are capable of being trained to provide abortions, the NHS would need to ensure that capacity exists to provide:

    (a)  Choice of surgical or medical procedure to clients;

    (b)  Requisite helpline support services;.

    (c)  Doctor supervision for all surgical abortions.

September 2007

354   Figures from Department of Health (2007) Statistical Bulletin; Abortion statistics, England and Wales: 2006. Back

355   Late Abortion; a research study of women undergoing abortion between 19 and 24 weeks gestation MSI 2006. Back

356   Roger Ingham et al (2007) Second Trimester Abortions in England and Wales University of Southampton. Back

357   Marlow, Neil et al (2006) "Neurologic and Developmental Disability at Six Years of Age after Extremely Preterm Birth" in The New England Journal of Medicine January 2006 Vol 352 No 1. Back

358   Data from the Confidential Enquiry into Maternal and Child Health Why Mothers Die 2000-02 RCOG Press 2004-calculation our own. Back

359   MSI (1999) General Practitioners: Attitudes to abortion. Back

360   Warriner et al "Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial" in The Lancet 29 November 2006. Back

361   MSI (1999) General Practitioners: Attitudes to abortion. Back

362   Population Issues in the 21st Century; the role of the World Bank World Bank 2007. Back

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