Submission from the Independent Advisory
Group on Sexual Health and HIV
The Independent Advisory Group on Sexual Health
and HIV would like to submit the following response to the Science
and Technology Committee enquiry into scientific developments
relating to the Abortion Act 1967.
1. THE SCIENTIFIC
(a) developments, both in the UK and internationally
since 1990, in medical interventions and examination techniques
that may inform definitions of foetal viability; and
Ultrasound scans early in pregnancy are much
more accurate at diagnosing intrauterine pregnancy and confirming
gestation and viability. Technological advances in Obstetrics
and Neonatal Paediatrics, in ultrasound and cytogenetics for prenatal
diagnosis and in-utero surgery for fetal treatments are
ongoing. A wider range of foetal abnormalities can be detected,
or refuted, and there is increased capacity for treatment of the
foetus in utero and baby post delivery. It is argued that abortions
should not be performed in pregnancies where the fetus may survive.
Data is available on the survival and subsequent disability (or
lack of disability) of the very premature eg the Epicure Study1
in which infants born before 26 weeks were followed up till six
years of age. However, in births up to 23 weeks gestation, only
7% survived to discharge. Of these 24 children, 63% suffered moderate
or severe disability at the age of six. However, the conclusive
diagnosis of serious foetal abnormality may still take late into
the second trimester or later (for example, awaiting the outcome
of amniocentesis for genetic abnormality or the outcome of an
anomaly scan), and for those women who feel they cannot continue
with such a pregnancy, we believe the need for later abortion
procedures continues. A 1987 paper produced jointly by the BMA,
Royal College of Obstetricians and Gynaecologists (RCOG), Royal
College of General Practitioners (RCGP), Royal College of Midwives
(RCM), British Paediatric Association and the Clinical Genetics
Society considering the advantages and disadvantages of imposing
an 18 week gestational age limit on legal abortion stated that
late diagnosis of malformation was inevitable in some pregnancies.
It went on to say "it would be inhumane to these mothers,
their babies and families to insist on the continuation of a pregnancy
when the fetus was known to be seriously abnormal"2
These technical advances have also brought into
question the foetus' ability to experience pain, foetal movements
and expressions being attributed to "feeling". Some
believe this is dictated by biological development, other that
it also requires cognitive faculties, not developed until much
later in pregnancy or even in post natal life. The evidence to
date is limited but a thorough review of the scientific evidence
published in the Journal of the American Medical Association in
2005 concluded that the perception of pain is unlikely below 24
weeks gestation (22 weeks from conception); for example cutaneous
withdrawal reflexes and hormonal stress responses present earlier
in development not being explicit or sufficient evidence of pain
perception and giving evidence for this statement.3
(b) whether a scientific or medical definition
of serious abnormality is required or desirable in respect of
abortion allowed beyond 24 weeks;
We believe it is desirable to define a serious
abnormality but accept it may not always achievable ie to absolutely
confirm whether there is or is not a serious abnormality, as follows;
(i) precisely defining the abnormality will
not always be possible; diagnostic techniques are not sufficiently
advanced to be able to absolutely precisely define the abnormality
and therefore consequently predict the "seriousness"
of the outcome;
(ii) definition of the word "serious"
as it can be to the fetus who becomes the child (if surviving)
intellectually, physically or socially, or to the child's family;
a family rejecting of a child unwanted due to disability can result
in poor outcomes in both the mother20 and the child and for society
(ref Czech study). 22
An exhaustive list of "serious abnormality"
is therefore unachievable for the reasons given. Having a fetus/child
with the absolute diagnosis of a known abnormality eg Down's syndrome
is still an unknown quantity, from how much one/other/both parents
can love the child and give the life every child deserves to how
severely affected the fetus/ child will be physically, emotionally
We believe you cannot put a scientific definition
on "serious abnormality" but can a medical one based
on what is agreed between the mother of the pregnancy and the
clinicians in charge of her case, taking into account all clinical
information available (obstetric and with information from other
pertinent specialists eg paediatrician) and the wishes of the
mother (ideally parents but ultimately the decision lies with
the mother). The Act does not give any guidance about how "serious
handicap" should be defined and nor have the courts given
any guidance as to how this phrase should be interpreted. The
RCOG has listed a number of factors that should be taken into
consideration when assessing individual cases,4 as has the BMA.5
Adequate and unbiased information to enable
decision-making is critical. This situation would benefit from
having national clinical guidelines/standards set, laying out
what information should be available and what staff is involved.
2. MEDICAL, SCIENTIFIC
(a) the relative risks of early abortion
versus pregnancy and delivery;
there are many references (scientific evidence)
in the literature as to the relative physical safety of first
trimester abortion as compared to term delivery given both are
undertaken in safe conditions.6 A paper this year in the New England
Journal of Medicine7 reported lack of evidence for early medical
abortions increasing the risk of spontaneous abortion, ectopic
pregnancy, preterm birth, or low birth weight in subsequent pregnancy
compared to surgical abortions, given previous research had shown
the safety of surgical abortion. There is the defined condition
"post natal depression" accepted by psychiatrists but,
psychiatrists have yet to define a "post abortion syndrome".
The US House of Representatives Committee on Government Operations
(1989) under Surgeon General Koop failed to find evidence for
this syndrome.8 No overall increase in psychiatric morbidity was
found in an English study.9 Research proposes that severe negative
reactions are rare and can best be understood in the framework
of coping with a normal life stress. 10
(b) the role played by the requirement for
two doctors' signatures; and
two signatures were put into the 1967 Abortion
Act to show the seriousness of the decision to terminate. Clinical
standards are maintained through informed consent and the adherence
to Good Practice Guidelines such as those of the Royal College
of Obstetricians and Gynaecologists.6 We would argue that if the
issue is the maintenance of standards, then that is addressed
by commissionable and performance managed national clinical guidelines.
There is an argument to wish the involvement of two appropriately
trained and experienced clinicians in more complex cases eg fetal
abnormality, the very young and the vulnerable to evidence the
case has been given the clinical involvement it merits which we
support. If this were to be the case, good practice may suggest
there are professionals as appropriate as doctors to fulfil this
role. However, this is a separate issue from signing the HSA1
which is not just one but two persons having the right to have
ultimate say what is or is not in the interest of another consenting
person (who by definition has been judged competent to weigh all
pros and cons and reach a conclusion herself ie is fit to give
informed consent). We know of no scientific or medical evidence
supporting the need for two signatures and question the right
of any person to veto the rights of a competent other to make
decisions about their own health and wellbeing.
The current use of the Abortion Act by the population
and the profession (98% are done under clause C or D, though this
is all gestations) and the ability to sign the HSA1 without seeing
or examining the woman is on its own evidence that the two signatures
are anachronistic. Overall, polls show women support the right
to abortion. 11 The GMC Guidance that if a doctor cannot support
a request for abortion, alternative provision must be offered
is also evidence for the belief in a woman's autonomy to seek
help. The refusal to sign HSA1 does not prevent a woman from going
to another provider for a signature.
We know of no research in this area ie the role
played by the Doctor re HSA1 but there are surveys re women's
attitudes, opinions and wants.
one signature is unlikely to cause delay as
the HSA1 is usually signed by the doctor doing the medical aspects
of the pre-assessment: the need for two signatures has the potential
to cause delay. However, it is difficult to tease out how much
delay is related to signatures. Delay increases clinical risk
and may prevent access to early medical abortion (as opposed to
surgical). Women commonly have to find a doctor who will refer;
few NHS provided services have self referral. The referring doctor
may or may not provide a signature. Nurse -led services by definition
cannot provide signed HSA1s with referral. Time can be spent while
the signature is sought (good services eg Liverpool, Hull, ensure
signatures as part of the service but this does not have to be
the case). Also, some services send women back to their GPs for
the second signature when the abortion has been granted by the
provider service; the woman is then put in the difficult position
of finding a signatory if her GP will not sign. Finding two signatures
have the potential for causing further stress/distress to the
woman who is already distressed. She goes to someone to ask for
referral and risks being made to feel bad about herself/turned
away and told to go elsewhere, a cause of short-term distress.
12 It could be argued this is about service provider attitude
and nothing to do with HSA1s but right now most women access abortions
through their GPs or Family Planning clinics (women will guess
access is available via the GP but many are not aware of access
through their FP service) 13 and do not know the GP/FPs' clinicians
stance on the topic14 (this alone is stressful). 15 It therefore
does not make sense, in the absence of any evidence otherwise,
for the system per se to be a source of distress and possible
delay unless it is shown there is the need for two signatures.
(c) 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
Nurses and midwives in the UK already take part
in many aspects of abortion care; many early medical abortion
services are increasingly nurse led and nurses and midwives undertake
patient care in late medical abortion. What nurses are allowed
to do vary from State to State in the USA. As of January 2004,
trained advanced practice clinicians were providing medical, and
in some cases, early surgical abortion in 14 states. 16 Nurses
and midwives run services in South Africa with excellent safety
profiles. 17 Nurses already undertake highly skilled surgical
services in gynaecology and other surgical specialties. Given
the evidence, we consider enabling trained, competent nurses/midwives
to carry out early surgical procedures should be both safe and
The evidence is that it is perfectly safe for
the second stage of early medical abortion to be carried out at
home within the structure of properly organised services. 18
3. EVIDENCE OF
There are many publications on the physical
risks of abortion in the short and long term (infection/ haemorrhage,
injury in the short term, infertility secondary to infection and
rarely injury in the long term; debate is ongoing on increased
risk of miscarriage and pre-term delivery. There is no evidence
for an increased risk of breast cancer, placenta praevia
or ectopic pregnancy.) These are well quantified and presented,
along with actions to minimise risk, in the RCOG Guidelines on
Abortion6 and subsequent research.
There is much published on the adverse long-term
psychological outcomes but many of he studies are of poor scientific
quality eg the samples are not representative of the population.
The American Psychological Association and American
Psychiatric Association do not recognise "Post Abortion Syndrome"
through lack of evidence.
Adler has given evidence to US House of Representatives
(March 16, 1989) 19 in which she summarises studies by saying
the predominant feeling following abortion is relief and happiness,
the incidence of severe negative reaction is low and factors are
known which put women at greater risk (eg planned pregnancy, second
trimester procedures, partly due to the nature of women accessing
later abortions, poor support) and she published on the emotional
responses following abortion, positive and negative. 12 The Koop
Report could find no conclusive evidence for mental health problem.8
There is not a lot of clinical study on restriction
to access. A paper from the UK on a large cohort study (13,000
women)by GPs reporting psychiatric morbidity showed psychiatric
disorder no higher after abortion than pregnancy Pre-existing
psychiatric illness was a risk for both groups. The abortion group
showed more deliberate self harm but greater in those refused
an abortion, indicating confounding variables such as adverse
social factors.9 A Swedish survey showed significant emotional
disturbance in 24% of women at follow-up with one third of these
mothers judged to be providing a poor environment for their children.
20 The evidence is children of unwanted pregnancies forced to
continue do less well than controls ie wanted children. A rigorously
control matched study published in 1980 showed teenagers whose
mothers had been denied abortion had poorer school performance,
more adverse psychological symptoms and more likelihood of registration
with social services. 21 A long term follow up study from Prague22
(Born Unwanted, 35 years later) with long-term follow up showed
the adverse effect on the children of women denied abortion compared
to controls; poorer school performance and more behavioural problems
as children and more criminality, job dissatisfaction and poorer
socialising as young adults .
1 Marlow N et al Neurologic and developmental
disability at six years of age after extremely preterm birth.
N Engl J Med. 2005; 352 (1):9-19.
2 Royal College of Obstetricians and Gynaecologists,
Royal College of Midwives, Royal College of General Practitioners,
British Medical Association, British Paediatric Association, Clinical
Genetics Society. Report on the advantages and disadvantages of
imposing an 18 week gestational age limit on legal abortion. London:
Royal College of Obstetricians and Gynaecologists. 27 November
1987: para 3.1.
3 Lee SJ et al. Foetal pain: a systematic
multidisciplinary review of the evidence. JAMA 2005; 294: 947-54
and correspondence JAMA 2006;2 95:159-161.
4 Royal College of Obstetricians and Gynaecologists.
Termination of pregnancy for fetal abnormality in England, Wales
and Scotland. London. RCOG Press. 1996.
5 British Medical Association Ethics Department.
Medical ethics today. Th e BMA's handbook of Ethics and Law. 2nd
ed London: BMJ Books. 2004:242-3.
6 Royal College of Obstetricians and Gynaecologists.
The Care of Women Requesting Induced Abortion. National Evidence-based
Clinical Guidelines. 2004. www.rcog.org.uk
7 Virk J et al. Medical abortion and the
risk of subsequent adverse pregnancy outcomes. N Engl J Med 2007;357:
8 Medical and Psychological Impact of Abortion.
Hearing before the Human Resources and Intergovernmental Relations
Subcommittee of the Committee on Government Operations House of
Representatives. One Hundred First Congress.
9 Gilchrist AC et al. Termination of pregnancy
and psychiatric morbidity. B J Psych 1995; 167: 243-8.
10 Adler NE et al. Psychological responses after
abortion. Science,1990 ; 248, 41-44.
11 Women's perceptions of abortion law and practice
in Britain, 2002. Independent survey by BMRB Social Research for
Marie Stopes. This gave little support for doctors having anything
but a consultative role in decisions relating to fertility regulation.
12 Adler NE (1975) emotional responses of women
following therapeutic abortion. Am J Orthopsychiatry 45(3) 446-454.
13 A Quest for Abortion; Research from Voice
for Choice presented at the All-Party Parliamentary Pro-Choice
Group, December 1999.
14 Obstruction by clinicians but not to do with
2 signatures specifically; Late; a study of women undergoing abortion
between 19 and 24 weeks. MSI 2004.
15 Case studies from General Practitioners Attitudes
to Abortion. A report by MSI. June 1999.
16 Joffe C, Yanow S. Advanced practice clinicians
as abortion providers: current developments in the United States.
Reprod. Health Matters. 2004;12 (24 suppl):198-206.
17 Warriner IK et al rates of complications
in 1st trimester manual vacuum aspiration done by doctors and
midlevel providers in South Africa and Vietnam; a randomised controlled
equivalence trial. Lancet 2006;368:1965-72.
18 Fiala C et al Acceptability of home
use of misoprostol in medical abortion. Contraception 2004;70:
19 Statement of Nancy E Adler. For: Medical and
Psychological Impact of Abortion. Hearing before he Human Resources
and Intergovernmental Relations Subcommittee of the Committee
On Government Operations House Of Representatives. One Hundred
First Congress. 1st session. March 16, 1989.
20 Hook K. Refused abortion. Acta Psychiatrica
et Neurologica Scandinavica 1963;39. Suppl 168:3-156.
21 Blomberg S Influence of maternal distress
during pregnancy on postnatal development. Acta Psychiatrica
et Neurologica Scandinavica 1980;62: 405-17.
22 David HP. Born Unwanted, 35 years later:
the Prague Study. Reprod. Health Matters. 2006;14: 181-90.