Memorandum 43
Submission from the British Association
of Perinatal Medicine
SCIENTIFIC DEVELOPMENTS
RELATING TO
THE ABORTION
ACT 1967
Further to our telephone conversation, I would
like to thank you for contacting the British Association of Perinatal
Medicine (BAPM) to give an opinion on the Terms of Reference of
the Select Committee's Review of the Scientific Developments Relating
to the Abortion Act 1967. I apologise that this letter is not
on our official BAPM headed note-paper. Our administrator is away
on holiday and I have recently taken over as Honorary Secretary.
You will appreciate that the time frame given
to BAPM to produce a reply has been rather short and I note that
you did admit that the Select Committee had failed to identify
that the view of BAPM would be of value. As such I have not been
able to consult with the wider membership on this issue. It is
worth noting that BAPM has over 800 members from the neonatal
and obstetric community and would, I am sure have a number of
views on this issue. BAPM assumes that you have consulted with
the Royal College of Obstetricians (RCOG) to whom the Abortion
Act has most relevance in clinical practice.
BAPM is also delighted to hear that you would
like a representative of BAPM to attend a workshop on 10 October
2007 to assist the Committee in its deliberations. Professor Neil
Marlow is the President of BAPM and at the present time is on
holiday, but returns on 25 September. He is a leading expert on
the outcome of babies born preterm especially at the limits of
viability. Clearly, from your Terms of Reference, it would be
this group of infants to whom BAPM would have a significant opinion
about their outcome. I have emailed Professor Marlow to try to
ensure that he is made aware of the Workshop and I hope that he
is able to attend.
BAPM would wish the Select Committee to be cognisant
of the fact that there is a growing body of research reporting
on the outcome of the pre-term infant below 24 weeks of gestation
("limits of viability"). This pivotal research, on UK
Infants, is beginning to give us a much clearer view on not only
the prospects for survival, but more importantly the prospects
for quality survival for this vulnerable group of infants. I have
enclosed with this letter the conclusions and recommendations
of the recently published Nuffield Council for Bioethics Report
into the management of babies at the limits of viability. Whilst
the Nuffield Council for Bioethics focus was on the management
of the extreme preterm infant, the information contained in the
full report including relevant references would give a clear steer
to the deliberations of the Select Committee.
Your Committee should note from this review
that they have relied heavily on the comprehensive follow up of
a cohort of babies born in 1995 (Epicure), below 26 weeks of gestation,
who have now been followed to the age of 12 years.
Interestingly, BAPM has recently completed a
further survey of the outcome for babies under 26 weeks of gestation
in 2006 and the results of this work are just becoming available
(Epicure 2). I will not be able to quote the exact outcomes for
babies in Epicure 2 as the data is being analysed. However early
indications are that, for infants below 24 weeks of gestation,
the survival to discharge home was very similar between the cohort
of 1995 and that of 2006. Headline figures of approximately 10-15%
survival were found. This is important for those working in perinatal
care, who in general, do not believe that the survival for babies
born below 24 weeks of gestation has improved to such an extent
that they would see any value in redefining the lower limit of
viability. Naturally a small number of these infants below 24
weeks of gestation do survive but BAPM would be concerned that
a lowering of the legal definition of viability would imply that
quality survival has improved for infants below the present limit
of 24 weeks. The evidence for the UK population, to date does
not support this.
Clearly, there are many social, moral and ethical
issues around abortion, some of which your Committee will be discussing.
In the Perinatal community, we have developed a number of guidance
notes to all clinicians managing the pre-term infant which has
made it clear that the survival rates for babies below 24 weeks
continues to be poor without any obvious evidence that advances
in medical science and diagnostic tests are likely to change this
for the foreseeable future.
It is also worth noting that it is accepted
practice in neonatal care on agreement with parents and the clinical
team, to not provide full intensive care for all babies who are
born below 24 weeks of gestation, and on occasion for those born
in poor condition above this gestation. As our understanding of
the outcomes has become clearer, many parents are choosing to
not subject their baby to full intensive care support and would
prefer a palliative care approach to their management.
Our conclusions to the limits of viability debate
is that, if the Select Committee is basing assumptions on the
need to lower the limit of viability on improvements to outcome
for babies born below 24 weeks, then the present evidence in the
UK does not support this. If, however, the Committee did conclude
that it wished to lower the limits because it believes that there
was evidence to justify this, then it is hard to see the limit
being lowered much further than a move from 24 to 23 weeks. BAPM
is unlikely to support this approach for the reasons outlined
above.
The issue of complex congenital abnormality
is a different debate and should probably be separated with respect
to the work of the Committee. We are, undoubtedly able to assess
babies in the antenatal period using improved scanning and the
advent of fetal MRI scanning. The latter technique has allowed
us to investigate the fetus before birth with respect to serious,
suspected, brain abnormalities. This has then allowed us to inform
parents about the likely outcome for their baby. A Fetal Medicine
specialist would wish to consider the options with the family
in the face of a complex and serious congenital abnormality for
either a late termination or the alternative of delivery with
neonatal palliative care. Our ability to provide palliative care
to babies and support for their family is improving all the time.
BAPM is about to embark on a working group to produce a framework
for such practice. This framework is expected to report by April
2008. BAPM would value some guidance for its members in the perinatal
community on what constituted a serious congenital abnormality,
for which the option of late termination would be considered acceptable.
The recent media interest in this subject has made the perinatal
community very nervous about its actions and, whilst we would
clearly not comment on any individual cases, BAPM would value
some clearer guidance on this issue.
The final issue which BAPM would wish to draw
to your attention is the present legal position linked to the
late termination. It is BAPM's understanding that following the
institution of a late termination of pregnancy beyond 23 weeks
of gestation, if the baby is born alive and subsequently dies
from the effects of prematurity, rather than the reason for which
the termination was being performed, it is our understanding from
my obstetric colleagues that there could be the serious accusation
of attempted manslaughter. It would appear that Coroners are taking
a varying view on this issue. It would, therefore, seem appropriate
that this clinical situation is addressed in a more formal sense
within any central guidance. BAPM would have expected the RCOG
to have given views on this issue.
BAPM hopes the information enclosed in this
letter gives the Select Committee some useful pointers to the
issues. BAPM fully understands that this is a complex social,
moral, ethical and legal issue and we will be delighted to provide
further opinion on the issues being covered in the Terms of Reference
if considered appropriate.
October 2007
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