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.
1. THE 24-WEEK
UPPER TIME
LIMIT
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.
2. THE REQUIREMENT
FOR TWO
DOCTORS' SIGNATURES
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.
3. THE POTENTIAL
ROLE OF
NURSES AND
MIDWIVES
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.
4. THE ADVERSE
HEALTH OUTCOMES
OF RESTRICTED
ACCESS TO
ABORTION
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.
5. SUMMARY RECOMMENDATIONS
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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