Select Committee on Science and Technology Written Evidence

Memorandum 43

Submission from the British Association of Perinatal Medicine


  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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