Select Committee on Science and Technology Written Evidence
The charity BPAS (the British Pregnancy Advisory
Service) is the largest single provider of early medical abortion
in Europe (the "abortion pill" method, used at under
nine weeks' gestation) having been largely responsible for introducing
this non-invasive method to the UK in 1992.
BPAS is also a specialist provider for women
presenting late in pregnancy for abortion, which involves relatively
small numbers of patients, but which tend to be women in especially
complex and sensitive circumstances. Annually BPAS undertakes
80% of the abortions taking place between 20 weeks gestation and
23 weeks and five days' gestation in England and Wales.
BPAS will limit our response to our experience
of issues concerned with the safe delivery of an up-to-date, client-focused
abortion service. BPAS' view, shared by the medical community
internationally, is that abortion is a safe procedure, and an
essential provision to be offered in response to the serious public
health problem posed by unintended pregnancy. Approximately 55,000
women each year have treatment to terminate a pregnancy at BPAS,
after attending for non-directive pregnancy counselling and information.
Over 85% of BPAS' not-for-profit services are performed under
contract on behalf of the NHS.
This submission states that:
1. Response to call for evidence relating
to: (2) medical, scientific and social research relevant to the
impact of suggested law reforms to first trimester abortions such
as: (a) the relative risks of early abortion versus pregnancy
1.0 The risk of maternal death from legal
abortion is associated with the lowest risk of adverse outcome
resulting from pregnancy. Of the alternatives to abortion, live
birth poses an intermediate risk and ectopic pregnancy and fetal
death pose the highest risk. This holds true well beyond the "early"
stages of abortion in the first 12 weeks' gestation. Even at the
latest stages of legally-available abortion, abortion is not more
risky than birth.
1.1 Of the 106 maternal deaths directly
associated with pregnancy, as reported by the Confidential Enquiry
into Maternal and Child Health (CEMACH) in their most recent report
(2000-02), three deaths were associated with legal termination
of pregnancy. The majority were associated with complications
of late pregnancy and delivery including thrombosis and thromboembolism,
hypertensive disorders and haemorrhage.
1.2 Early abortion has been shown to have
no adverse effect on future pregnancies.
2. (2) medical, scientific and social research
relevant to the impact of suggested law reforms to first trimester
abortions such as: (b) the role played by the requirement for
two doctors' signatures
2.0 It is important to note that the legal
requirements for two doctors' signatures to confirm that the woman
meets the legal grounds for abortion is a separate legal exercise
to a clinical assessment of the patient to determine the most
The requirement for a second referral doctor's
signature to confirm that the woman meets the legal grounds for
abortion conflicts with established medical ethical principles
of the autonomy of competent patients and is redundant in medical
terms. No medical benefit is conferred to the woman by its retention,
as it only serves to confirm that the abortion is being undertaken
within the terms of the 1967 Abortion Act.
2.1 Currently, the requirement for two doctors
to certify that a woman meets the legal grounds for abortion has
the potential to delay treatment. It may be difficult for a woman
who is concerned about confidentiality to find two doctors to
approve her abortion request. There is no central monitoring of
delays to treatment of this type, but recently, Tony Calland,
the Medical Ethics Committee Chair of the British Medical Association
(BMA) said that "some women waited up to 13 weeks [gestation]
to have their abortion approved by two doctors and removing this
requirement would reduce such a wait and the associated risks".
The requirement for two signatures for solely legal purposes also
increases treatment costs by introducing unnecessary bureaucracy.
2.2 The Department of Health's documentation
form (HSA1 form) for the recording of each abortion that takes
place, provides for both the first and second signatory doctors
to "sign unseen" that the woman meets the legal grounds,
on the recommendation of other members of the clinical team. This
has been discussed with, and confirmed as lawful practice by,
the Department of Health. (In terms of clinical assessment however,
at BPAS it is considered good practice under the current law,
for at least one of the doctors to have seen the woman before
2.3 The Committee will be aware that a majority
of BMA doctors voted for the removal of this requirement in 2007,
arguing that abortion (in the first trimester) should be provided
on the basis of informed consent as other medical treatments are.
BPAS would support this position being adopted
up until the current legal time limits.
A woman's clinical assessment for treatment
and confirmation that she meets the legal grounds for abortion
does not require more doctors in the second trimester, than in
the first. There is no reason why the confirmation of the legal
grounds for abortion requires more doctors in the second trimester
than in the first.
2.4 As two doctors can already confirm at
all gestations within the current legal limits that a woman meets
the legal requirements on the recommendation of a nurse, it would
seem logical for nurses to be able to sign in their own right
if such a form is required. This would be sensible especially
where pertaining to what are currently already virtually nurse-led
methods, such as early medical abortions (EMA), or the abortion
pill, which is offered up to nine weeks' gestation.
3. (2) medical, scientific and social research
relevant to the impact of suggested law reforms to first trimester
abortions such as: (c) the practicalities and safety of allowing
nurses or midwives to carry out abortions
3.0 The wording of the 1967 Act enables
abortions to be conducted lawfully only by "registered medical
practitioners". This is interpreted as meaning only doctors
registered by the General Medical Council, and to exclude nurses
and midwives. This definition is now out-dated because today's
modern, less invasive early abortion methods are suitable to be
performed by nurses and midwives. Forty years ago when the Abortion
Act was drafted, these methods were not available and the nursing
role was much more restricted.
We believe it would be appropriate for suitably
trained nurses and midwives to be permitted to perform early abortions
in Britain as they do in other countries, such as the United States
and South Africa.
3.1 Early medical abortion (EMA) is available
up to nine weeks' or 63 days' gestation. This increasingly popular
non-invasive method relies on the administration of two sets of
prescribed medication. During the 16 years that BPAS has provided
EMA, we have developed a nurse-led service which has minimised
the role of the doctor. This development was in response to observations
that nurses are better able to deliver this service as they can
often develop a greater rapport with clients. The EMA method requires
particularly open and clear communication as the patient is central
to the participation in, and management of her treatment. The
legal requirements are met by the doctor signing the prescription
for the medication, after it has been confirmed by two doctors
that the legal grounds for abortion have been met.
3.2 If nurses became legally able to perform
some methods of abortions, it would then be possible to develop
a nurse-prescribing protocol or a "Patient Group Direction"
that would allow an abortion nurse to take full responsibility
for treatment, as nurses do in other areas of medicine. In BPAS'
view, reducing the involvement of doctors would enable them to
use their time in the clinic most efficiently and would reduce
costs of the procedure without compromising the quality of care.
3.3 Manual vacuum aspiration (MVA) is a
method of early surgical abortion (offered from four weeks' to
12 weeks' gestation), which involves the removal of the contents
of the uterus using a gentle hand-operated suction pump. The level
of technical skill required to do this is of a similar level to
fitting a contraceptive "coil" (IUD/IUS) which BPAS'
and NHS family-planning trained nurses already routinely do. In
some regions of the United States, South Africa and commonly in
the developing world, nurses provide MVA treatment. In the UK,
the phrasing of the law means that only a doctor can provide this
3.4 In other areas of more technically-skilled
NHS practice, such as gastro-enterology and dermatology, trained
nurses have for several years been permitted, for example, to
pass investigation camera equipment (endoscopes) into the body
and to take skin biopsies. In sexual and reproductive healthcare,
nurse hysteroscopists are able to examine the uterus with a camera
and nurse colposcopists can examine the cervix with a camera and
also take tissue biopsies. It seems anomalous for the law to prevent
appropriately-trained nurses in abortion care from developing
their roles similarly.
3.5 Greater involvement of nurses in early
abortion care would also increase national capacity at early gestations
and so reduce treatment delays.
3.6 Later gestation medical induction abortion
is a method where the woman has chosen to go through induced labour
rather than undergo a surgical termination of pregnancy. This
is often chosen in situations of termination for fetal abnormality.
Midwives are particularly appropriate to carry out this procedure,
which involves offering the woman ongoing emotional support as
well as professional technical expertise in labour care. BPAS'
view is that it is not justifiable to legally permit midwives
to take responsibility for births at term, but not abortions,
which take place at an earlier gestation and are safer than labour
and delivery of a full-term pregnancy.
4. (2) medical, scientific and social research
relevant to the impact of suggested law reforms to first trimester
abortions such as [...] allowing the second stage of early medical
abortions to be carried out at the patient's home
4.0 At present, the early medical abortion
(EMA) or "abortion pill" method, which is used up to
nine weeks' or 63 days' gestation, involves the woman swallowing
a mifepristone (RU 486) tablet at a BPAS clinic, after which she
may either return home or can occupy herself for a few hours nearby
to the clinic. This medication blocks the pregnancy hormones so
that the pregnancy ceases to be viable. At least six to eight
hours later, or on the following day, she is required to return
to the clinic, where the second part of the treatment, a dosage
of the drug misoprostol, is then administered vaginally with a
tampon, or is swallowed. Misoprostol causes the uterus to contract
and to expel the pregnancy much like a miscarriage. Women go straight
home from the clinic after taking misoprostol, in order to make
themselves comfortable before this process starts.
4.1 Women are obliged to make a second journey
back to the clinic to take the second medication (misoprostol)
solely because the law specifies that an abortion may only be
carried out in hospitals or a specially approved location. Currently
the Department of Health interprets this as meaning that both
administrations of the two-stage drug regimen must be administered
within an approved location. There is no clinical justification
for two separate visits to a clinic.
4.2 In Norway, which has a law similar to
the UK, only the mifepristone must be taken in a clinic, as this
is regarded as the abortifacient. Misoprostol is viewed as a supporting
medication, because it is taken to enable the safe and prompt
expulsion of the products of conception. The requirement for two
clinic visits can be burdensome for women with caring or other
responsibilities to manage at home and can mean that women without
a local EMA service near their homes are not able to choose EMA
at all. The requirement to administer the misoprostol at a second
appointment in a registered place adds unnecessary cost to the
procedure. The removal of this requirement could increase national
capacity for early abortions, helping to reduce treatment delays.
4.3 Self-administration of misoprostol at
home is common in most countries where EMA is available. From
a clinical perspective, arguably it would be more appropriate
for women to administer the misoprostol at home, as the time from
treatment to the expulsion of the pregnancy can be variable and
unpredictable. There is no evidence that self-administration of
tablets is unsafe, or that home-use is unacceptable to patients.
4.4 UK women in other medical situations
can already self-administer misoprostol at home. For example women
who have experienced a spontaneous miscarriage are given a dose
of misoprostol to take home and insert vaginally themselves, in
order to ensure the prompt and safe expulsion of the miscarried
pregnancy. BPAS sees no reason why abortion patients should continue
to be excepted from this provision.
5. (3) Evidence of long-term or acute adverse
health outcomes from abortion
5.0 BPAS is not aware of long-term or acute
adverse health outcomes arising specifically from abortion, although
as with any medical treatment, complications can result. Abortion
is a very safe procedure compared to many other medical interventions
and earlier abortion is particularly safe.
5.1 Abortion has not been shown definitively
to be associated with adverse psychological health outcomes. The
British Royal College of Obstetricians and Gynaecologists (RCOG)
considers published studies on this issue, when drawing up its
evidence-based guidance on abortion. The RCOG states, on the basis
of the available evidence: "Some studies suggest that women
who have had an abortion may be more likely to have psychiatric
illness or to self-harm than other women who give birth or are
of a similar age. However, there is no evidence that these problems
are actually caused by the abortion; they are often a continuation
of problems a woman has experienced before".
5.2 As an abortion provider since 1968,
BPAS has had little experience of women undergoing long term negative
psychological consequences from abortion. We provide a post-abortion
counselling service and our staff see a small number of women
each year experiencing feelings of regret. These feelings are
usually focused on regret about the circumstances of the unplanned
pregnancy. Sometimes women report that they regret the abortion,
while still believing it was the right decision for them at the
time. Some women continue to hold the belief that abortion is
morally wrong, while continuing to believe it was right for them,
and that choosing abortion was the "least worst" option
available to them.
5.3 BPAS believes it is essential that women
continue to have access to pre- and post-abortion counselling,
to enable informed decision-making and support whatever the woman
6. "(3) Evidence of long-term or acute
adverse health outcomes ... from the restriction of access to
6.0 Unintended pregnancy continues to be
a serious public health problem. Restriction of access to abortion
would impact adversely on the health of large numbers of women
experiencing unintended pregnancy.
6.1 Compelling evidence on adverse health
outcomes from restriction of access to abortion in the UK can
be found in a review of maternal mortality associated with abortion
prior to the 1967 Abortion Act, published by the Confidential
Enquiry into Maternal and Child Health (CEMACH).
This stated that: "the most striking change
during the first 50 years of this report has been the disappearance
of illegal, unsafe abortion as a cause of early pregnancy direct
deaths which followed the passage of the Abortion Act in 1967.
The first CEMACH Enquiry Report, covering the years 1952-54, described
153 deaths from `abortion', of which 108 at the least had been
procured illegally. [...] Around 30 deaths per year from illegal
abortion continued through the 1950s and 1960s. The first full
working year of the Abortion Act was 1969 and the number of deaths
`clearly due to illegal abortion', fell, that year to 17."
Worldwide, death and ill health are reported
where there is a lack of access to safe and legal abortion.
6.2 In the 2000-02 CEMACH enquiry report,
out of 15 deaths attributed directly to early pregnancy complications
(out of 106 maternal deaths directly associated with pregnancy
as a whole), three were attributed to termination of pregnancy.
6.3 In BPAS' experience, the denial of abortion
causes deep distress to women. We are concerned for the well-being
of women who present to us seeking abortion, but who are unable
to access treatment as they are beyond the legal gestational limit.
We ensure that these women are promptly referred into antenatal
care and are concerned about their needs for appropriate emotional
support to cope with this.
6.4 BPAS sees several hundred clients each
year who have travelled to Britain because abortion is illegal
in their own country. Typically, these women present at later
gestations, often into the second trimester because of the increased
costs and other problems associated with accessing information
and travelling. Our experience of collaboration with the Irish
Family Planning Association and the Crisis Pregnancy Agency in
Ireland suggests that women who travel may also have difficulty
accessing post-abortion advice and care and experience addition
psychological burdens because of the need to conceal the abortion.
6.5 BPAS is aware that young people aged
under 24, who are especially in need of quality sexual health
services, would be particularly at risk if greater restriction
was placed on abortion. The Brook Advisory Service has shown that
that confidentiality is key to young people's willingness to access
sexual health services. It is BPAS' experience that the great
majority of young people voluntarily involve their families when
accessing services in any case, and where they are not able to
do so, they report compelling reasons for this.
6.6 In a survey conducted on adolescent
BPAS clients in 2007, responding centres found that no client
aged under 16 had attended her abortion consultation or treatment
appointment alone. The most frequent accompanying person in any
category was one or both parents, with 56% of clients attending
with their mother, whether or not accompanied by additional escorts.
6.7 As a further potential source of delay
for women who seek to terminate a pregnancy, BPAS is concerned
that unlicensed, unregulated "Crisis Pregnancy Counselling"
networks (which often have a political or religious bias against
abortion) operate widely in the UK, outside the standards of the
Department of Health's Register of Pregnancy Advice Bureaux.
There is no central collection of the numbers
of these networks, which do not refer women for abortion or adhere
to any minimum standard of information-giving. A quick glance
at the websites of some "Crisis Pregnancy Counselling"
organisations shows that some poor quality information and advice
is offered about abortion or the health risks associated with
abortion by some of them.
6.8 BPAS is concerned that in some local
areas, unregulated services appear to have received funding support
from local NHS Primary Care Trusts and also to be permitted to
"train" doctors in local NHS hospitals.
6.9 BPAS would like to see "Crisis
Pregnancy Counselling" services required by law to be registered
and to adhere to minimum standards of non-directive, accurate
information-giving about pregnancy options and abortion and emergency
contraception. Where services will not refer a woman for abortion,
we believe that such services should be required by law to clearly
state this fact on their literature and publicity, as is required
in other countries.
There is no central collection of data on the
delays to treatment experienced by women seeking abortion after
attending unregulated "Crisis Pregnancy Counselling"
services. BPAS believes that the law should ensure that all women
with unintended pregnancies should be able to access clearly signposted,
non-directive advice and information meeting minimum quality standards,
to enable them to make an informed decision, and to facilitate
prompt referral for antenatal care, or abortion treatment as appropriate.
Approximately 55,000 women each year have treatment
for termination of pregnancy at BPAS after attending for non-directive
pregnancy counselling and information, which is monitored by and
registered with the Department of Health. BPAS is the largest
provider of early medical abortion in Europe (the "abortion
pill" method, used at under nine weeks' gestation) having
been largely responsible for introducing this non-invasive method
to the UK in 1992.
BPAS is also a specialist provider for women
presenting late in pregnancy for abortion, which involves relatively
small numbers of patients, but which tend to be women in especially
complex and sensitive circumstances. BPAS undertakes 80% of the
abortions taking place between 20 weeks' gestation and 23 weeks
and five days' gestation in the England and Wales each year, under
contract to the NHS. Beyond 24 weeks' gestation, all terminations
in the UK take place in NHS premises.
BPAS is regulated by the Healthcare Commission
in England, Healthcare Inspectorate Wales, NHS Quality Improvement
Scotland and the Department of Health. BPAS works closely on policy
and training issues with the Royal College of Nursing, Royal College
of Obstetricians and Gynaecologists, and the Faculty of Family
Planning and Reproductive Health Care. BPAS is a research-led
organisation and facilitates academic and Department of Health
research projects under the scrutiny of its independently-constituted
Research Ethics Committee.
The British Pregnancy Advisory Service (registered
charity number 289145) was set up in 1968 after the implementation
of the 1967 Abortion Act in order to provide services, train doctors
and provide premises for safe legal abortion, at a time when the
NHS not always able or prepared to provide abortion services.
BPAS' abortion treatments, comprehensive counselling
services, male and female contraceptive and sterilisation services
and sexually transmitted infection testing and treatment are all
not-for-profit. All of the charity's services are conducted according
to the relevant professional guidance under the scrutiny of BPAS'
independently-constituted Clinical Governance Committee. For further
information about the charity or its services, please see www.bpas.org.
This submission compiles evidence from:
Dr Patricia A. Lohr MD, MPH, Medical Director of
Mandy Myers RGN, MPhil, Director of Nursing at BPAS.
Professional affiliations, Memberships and declaration
In support of the Response from BPAS (the British
Pregnancy Advisory Service) submitted to the Science and Technology
Committee's Inquiry: "Scientific Developments relating to
the Abortion Act 1967"*
This Appendix offers an evidence basis in support
of the Response, grouped by the paragraph numbers that are used
in the Response.)
|1."(2) medical, scientific and social research relevant to the impact of suggested law reforms to first trimester abortions such as:|
|(a) the relative risks of early abortion versus pregnancy and delivery;"|
(1) "Despite impressive gains in safety in recent decades, pregnancy remains risky. [...] From early in pregnancy until some weeks after its conclusion, pregnant women are at increased risk of morbidity and mortality compared with women who are not pregnant. This review summarizes recent national data from the US Centers for Disease Control and Prevention, including vital statistics from the National Center for Health Statistics.
Ectopic pregnancy is substantially more dangerous (38 deaths/100,000 events) than either childbirth (nine) or legal abortion (less than one). The three leading causes of maternal death today are pregnancy-induced hypertension, hemorrhage, and pulmonary embolism.
Although comprehensive data on pregnancy-related morbidity are lacking, about 22% of all pregnant women are hospitalized before delivery because of complications.
Women of minority races have much higher risks of death than do white women, and the same holds true for older women and those with limited education.
For most women, fertility regulation by contraception, sterilization, or legal abortion is substantially safer than childbirth.'
|Grimes DA. "The morbidity and mortality of pregnancy: still risky business" American Journal of Obstetrics and Gynecology, 1994 May; 170 (5 Pt 2): 1489-94.)|
|(1) "The comparative safety of pregnancy outcomes has clinical and public health importance. Using national statistics for 1991 to 1999, I estimated the risk of maternal death associated with various outcomes. Abortion (legal and spontaneous) was associated with the lowest risk, live birth intermediate risk, and ectopic pregnancy and fetal death the highest risk."||
Grimes DA. "Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999"
American Journal of Obstetrics and Gynecology (2006) 194, 92-4)
|(1.1)Of 758 maternal deaths directly related to pregnancy in the UK between 1985-2002, 15 deaths (1.97%) were directly related to termination of pregnancy. Of 106 maternal deaths in the UK directly related to pregnancy in 2000-02, 3 were directly related to termination of pregnancy.||"Table 1.4, Number of maternal deaths reported to the Enquiry by cause; United Kingdom 1985-2002", p 30, "Why Mothers Die 2000-02", CEMACH|
|For more on this data, see Table 6.1 "Numbers of Direct Deaths in early pregnancy by cause, United Kingdom 1985-2002", shows in 2000-02, 15 direct deaths attributed to early pregnancy complications, 3 of which were attributed to termination of pregnancy.||
p 103, "Why Mothers Die 2000-02", CEMACH.
(1.2)"The long-term safety of surgical abortion in the first trimester is well established. Despite the increasing use of abortion by means of medication, limited information is available regarding the effects of this procedure on subsequent pregnancies.
We identified all women living in Denmark who had undergone an abortion for nonmedical reasons between 1999 and 2004 and obtained information regarding subsequent pregnancies from national registries.
Risks of ectopic pregnancy, spontaneous abortion, preterm birth (at 37 weeks of gestation), and low birth weight (<2,500 g) in the first subsequent pregnancy in women who had had a first-trimester medical abortion, were compared with risks in women who had had a first-trimester surgical abortion.
Among 11,814 pregnancies in women who had had a previous first-trimester medical abortion (2,710 women) or surgical abortion (9,104 women). We found no evidence that a previous medical abortion, as compared with a previous surgical abortion, increases the risk of spontaneous abortion, ectopic pregnancy, preterm birth, or low birth weight.
The gestational age at medical abortion was not significantly associated with any of these adverse outcomes."
2. (2) medical, scientific and social research relevant to the impact of suggested law reforms to first trimester abortions such as:
(b) the role played by the requirement for two doctors' signatures;
|Jasveer Virk, Jun Zhang and Jrn Olsen, "Medical Abortion
and the Risk of Subsequent Adverse Pregnancy Outcomes" New England
Journal of Medicine August 16, 2007, Number 7, Volume 357: 648-653,
2. Competent pregnant women in medical situations (aside from abortion) are legally permitted to make choices about their medical treatment on the basis of informed consent, without a doctor scrutinising their reasons. This applies even if their choice threatens or could end the life of the fetus. Abortion is exceptional in remaining legally contingent upon two doctors' approval of the woman's reasons for requesting medical assistance to safely end her pregnancy. "In St. George's Healthcare NHS Trust v S  3 W.L.R. 936, The Court of Appeal found that a competent adult woman was entitled to refuse a caesarean section, even if her decision would lead to the death of a 36 week old fetus. Judge LJ said: `The autonomy of each individual requires continuing protection, particularly when the motive for interfering is readily understandable, and indeed to many would appear commendable". He said "Pregnancy does not diminish a woman's entitlement to decide whether or not to undergo medical treatment. Her right is not reduced or diminished merely because her decision to exercise her right may appear morally repugnant". [...] If the law has established that a woman's decision should be respected, even if it will cause the death of a 36 week old fetus, is there some inconsistency with the Abortion Act's requirement that a woman's reasons for terminating a pregnancy of much shorter gestation must be judged acceptable by two medical practitioners?"
E Jackson, "Ethics and British Abortion Law"
|2.1, 2.3 "Early abortions should be available without the need for two doctors' approval, doctors at the [BMA] ARM agreed. Doctors leaders said removing the requirement of two signatures on a termination form would speed up the procedure and reduce risks. [...] Speaking outside of the meeting, MEC chair Tony Calland said some women waited up to 13 weeks [gestation] to have their abortion approved by two doctors and removing this requirement would reduce such a wait and the associated risks. Two doctors' signatures should not be necessary for abortions within the first trimester, the Representative Body said.||
"Call for end to two-signature rule in abortions", "Updates from the Annual Meeting" BMA News, June 27 2007
3."(2) medical, scientific and social research relevant to the impact of suggested law reforms to first trimester abortions such as:
(c) the practicalities and safety of allowing nurses or midwives to carry out abortions
3. The RCOG stated in 2007:
"The proposal... that present legislation would allow nurses to perform surgical abortions should be further explored.
The Royal College of Obstetricians and Gynaecologists (RCOG) believes that access to high quality family planning and termination of pregnancy services are essential factors in the provision of good health care for women. After appropriate encompassing training, many nurses working in the NHS have already taken on extended responsibilities.
If legislation allows, and only working closely as part of a medical team, the option of fully trained nurses helping to provide early surgical termination of pregnancy services merits further evaluation."
RCOG Statement on review article
"Can nurses legally perform surgical induced abortion?" Journal of Family Planning and Reproductive Healthcare, April 2007'
3 and 3.3
"South Africa's Choice on Termination of Pregnancy Act, which took effect in 1997, legalized abortion and stipulated that registered midwives can perform abortions for women with pregnancies of no more than 12 weeks' gestation. A program was initiated to train registered midwives throughout South Africa to provide abortion services at primary care facilities. From October 1999 through January 2000, an evaluation was conducted at 27 public health care facilities in South Africa's nine provinces to assess the quality of care provided by midwives who had been trained and certified to provide abortion services. Data were collected by observing abortion procedures and counseling sessions, reviewing facility records and patients' charts, and interviewing patients and certified midwives. Results: Of 96 abortion procedures performed by 40 midwives, 85 involved manual vacuum aspiration. Midwives' clinical practice was rated `good' in 75% of the procedures. No complications occurred during abortion procedures or as a result of the procedures, and no abortion clients died. Midwives consistently provided women with contraceptive counseling after the abortion, and most clients (89%) received a contraceptive method before leaving the facility. Conclusion: Midwives can provide high-quality abortion services in the absence of physicians. Training in abortion care should be systematically integrated into midwives' basic training. This training should use postabortion counseling as an opportunity to inform women about dual protection from unwanted pregnancy and sexually transmitted infections."
Kim Dickson-Tetteh and Deborah L Billings
"Abortion Care Services Provided by Registered Midwives in South Africa"
International Family Planning Perspectives, 2002, 28(3):144-150
3 and 3.3
"A hopeful note in the contemporary abortion environment in the United States is the expanding role of advanced practice cliniciansnurse practitioners, physician assistants and nurse-midwivesin first trimester abortion provision. Two national symposia in 1990 and 1996 approved the expansion of early abortion care to non-physicians. As of January 2004, trained advanced practice clinicians were providing medical, and in some cases, early surgical abortion in 14 states. This has required not only medical training but also political organising to achieve the necessary legal and regulatory changes, state by state, by groups such as Clinicians for Choice and the Abortion Access Project. Recent surveys in three states show a substantial interest among advanced practice clinicians in abortion training, leading to cautious optimism about the possibility of increased abortion access for women."
Carole Joffe, Susan Yanow
"Abortion Providers: Current Developments in the United States"
Volume 12, Issue 24, Pages 198-206
3.2. A literature review of research literature on prescribing both in the United Kingdom and in countries with comparable health care systems from 2000-03 found:
"broad support from patients and professionals for the use of different models of prescribing and supply of medicines in which health professionals adopted a wider prescribing role... evidence of improved patient access to medicines and services as a result of nurse prescribing, the use of patient group directions... Patients and nurse prescribers in several studies reported benefits of nurse prescribing, eg timeliness of treatment and improvements in the quality of care."
4."2. medical, scientific and social research relevant to the impact of suggested law reforms to first trimester abortions such as [...] allowing the second stage of early medical abortions to be carried out at the patient's home;
J Harris and J Taylor, C Mackie,
"Research Literature Review on Prescribing"
Research Findings No 40/2004
4.1 A study seeking to provide evidence regarding the safety, efficacy, and acceptability of 200 mg mifepristone followed by home administration of 400 mg oral misoprostol enrolled 376 women in a prospective, open-label, multicenter trial. Women were administered mifepristone in the clinic and were given two tablets of misoprostol to swallow at home 48 hours later. On day 15, women returned to the clinic for a gynecologic examination. Success was defined as a complete termination without surgical intervention or additional misoprostol by day 21. All participants completed an exit interview before discharge from the study.
Results: Of the women enrolled, 58.8% had gestations of between 43 and 49 days, 54.7% had had a previous abortion, and 76% had had a previous pregnancy. Of the 354 women included in the efficacy analysis, 324 (91.5%) had a successful termination.
The most common adverse effects reported by patients were pain or cramps (93.2%) and nausea (66.6%), followed by weakness (54.7%), headache (46.2%), and dizziness (44.4%).
Overall acceptability of the regimen was high, with 63.3% of women reporting that it was very satisfactory and an additional 23% reporting that it was satisfactory.
Conclusion: mifepristone followed in 48 hours by home administration of . . . misoprostol is effective, associated with rare severe adverse effects or adverse events, and acceptable for women seeking medical abortion of pregnancies of up to 49 days duration . . ".
Shannon C S, Winikoff B, Hausknecht R, Schaff E, Blumenthal PD, Oyer D, Sankey H, Wolff J, and Goldberg R.
"Multicenter Trial of a Simplified Mifepristone Medical Abortion Regimen"
Obstetrics and Gynecology,
2005; 105: 345-51.
4.1 "Studies from the USA have suggested the feasibility and acceptability of home medical abortion, however the issue has not been addressed in the UK. This study aimed to assess the feasibility, efficacy and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation.
Methods: Mifepristone 200 mg was given orally in hospital under nursing supervision. Women were provided with misoprostol tablets 600 microg and advised to take them sublingually 36-48 hours later. The main outcome measures were (1) feasibility, assessed through successful completion of abortion at home without the need for hospital admission, (2) efficacy, assessed through complete uterine evacuation without the need for further medical or surgical intervention and (3) women's acceptability of the procedure as assessed by questionnaire.
Results: A total of 49 women participated in this study. Of these, 48 women aborted at home while one opted to be admitted to hospital after receiving misoprostol at home. One woman underwent surgical evacuation five weeks following abortion for excessive bleeding and retained products of conception. A total of 43-44 (98%) women were satisfied with having the abortion at home.
Side effects experienced by women included nausea [80%], vomiting [42%], diarrhoea [42%], shivering [65%], tiredness [80%], headache [31%], hot flushes [35%], dizziness [62%] and unpleasant mouth taste [50%].
Conclusions: This study suggests the feasibility and acceptability of home self-administration of misoprostol for medical abortion up to 56 days' gestation. These findings need to be assessed in the context of a randomised trial".
Hamoda H, Ashok PW, Flett GM, Templeton A.
"Home self-administration of misoprostol for medical abortion up to 56 days' gestation".
Journal of Family Planning and Reproductive Health Care.
2005 Jul; 31(3): 189-92.
|4.2 "There are important issues to do with the provision and place of services, including medical (non-surgical) methods. Medical methods of abortion are carried out in only 24% of women seeking an abortion in England, when evidence suggests that where a choice is available, the uptake would be 60-70% of women".||
RCOG Statement on the BMA Medical Ethics Committee Briefing on First Trimester Abortions
5 June 2007
4.3 A study assessed the acceptability of home medical abortion to women in UK settings, based in four NHS gynaecology units in England and Scotland, where women underwent conventional, hospital-based, medical abortion up to nine weeks of gestation. Using a self-completed questionnaire, researchers explored the acceptability of abortion in hospital (including pain and bleeding experienced) and at home. Comparisons were made between centres (English and Scottish).
Results: 66% (366/553) of the questionnaires were returned. 228/320 said there was nothing that happened during abortion in the hospital that they would have been unable to cope with at home; 123/342 said they would have opted to have home abortion, had that choice been available. However, 219/342 indicated that they would prefer to have abortion in the hospital.
The majority of women said they would have coped at home with bleeding (280/355, 79%) and with pain if given analgesia (203/268, 76%)
Conclusion: This study suggests that most women would welcome being offered the choice of having medical abortion at home or in hospital. The development of home abortion must be seen as complementary, not an alternative, to hospital services.
Hamoda H, Critchley HO, Paterson K, Guthrie K, Rodger M, Penney GC.
"The acceptability of home medical abortion to women in UK settings"
British Journal of Obstetrics and Gynaecology.
2005 Jun; 112 (6): 781-5.
4.4 A US study looked at the effectiveness, safety, time to bleeding, and acceptability of misoprostol administered by vagina at home and repeated, if needed, after mifepristone was administered for abortion in women up to eight weeks' pregnant.
A prospective trial was conducted with women up to eight weeks pregnant wanting an abortion.
After receiving mifepristone orally, subjects self-administered vaginal misoprostol at home two days later. Subjects returned within seven days, and if the gestational sac was still present on ultrasound, a repeat dose of misoprostol was administered in the office.
Subjects completed a daily symptom log and a questionnaire on the acceptability of the procedures.
Results: Of the 166 subjects, 163 (98%) had a complete medical abortion. Three subjects presented with persistent bleeding and an incomplete abortion from 27 to 35 days after taking mifepristone and required surgical intervention. Vaginal spotting or bleeding occurred in 104 (62%) subjects before taking misoprostol, and 18 (11%) did not use misoprostol.
Bleeding occurred on average 3.5 hours (SD, 3.2) after taking misoprostol.
Six (4%) subjects required a second dose of misoprostol. Gastrointestinal side effects were common, mild, and brief.159 (96%) subjects agreed that the procedure went well, and 146 (90%) agreed that home administration of misoprostol was acceptable.
Conclusion: Two days after taking mifepristone, misoprostol administered by vagina was found to be safe, highly effective, and acceptable to women. Since only six subjects needed a second dose of misoprostol, conclusions about repeat doses are not possible. This procedure is a promising alternative to surgical abortion.
|Schaff E A, Stadalius L S, Eisinger S H, Franks P."Vaginal misoprostol administered at home after mifepristone (RU486) for abortion".Journal of Family Practice. 1997 Apr; 44 (4): 353-60.|
|5. "3. Evidence of long-term or acute adverse health outcomes from abortion"|
5. Advice on abortion risks from the RCOG is that:"16.1 The risk of haemorrhage at the time of abortion is low.It complicates around 1 in 1,000 abortions overall. The risk is lower for early abortions (0.88 in 1,000 at less than 13 weeks;4.0 in 1,000 at more than 20 weeks).
16.2 The risk of uterine perforation at the time of surgical abortion is moderate.
The incidence is of the order of 1-4 in 1,000. The risk is lower for abortions performed early in pregnancy and those performed by experienced clinicians.
16.3 Uterine rupture has been reported in association with mid-trimester medical abortion. However, the risk is very low, at well under 1 in 1,000.
16.4 Cervical trauma:the risk of damage to the external cervical os at the time of surgical abortion is moderate (no greater than 1 in 100). The risk is lower when abortion is performed early in pregnancy and when it is performed by an experienced clinician.
16.5 Failed abortion and continuing pregnancy:all methods of first-trimester abortion carry a small risk of failure to terminate the pregnancy, thus necessitating a further procedure. The risk for surgical abortion is around 2.3 in 1,000 and for medical abortion between 1 and 14 in 1,000 (depending on the regimen used and the experience of the centre).
16.6 Post-abortion infection:genital tract infection, including pelvic inflammatory disease of varying degrees of severity, occurs in up to 10% of cases. The risk is reduced when prophylactic antibiotics are given or when lower genital tract infection has been excluded by bacteriological screening.
16.7 Breast cancer:induced abortion is not associated with an increase in breast cancer risk.
16.8 Future reproductive outcome:there are no proven associations between induced abortion and subsequent ectopic pregnancy, placenta praevia or infertility. Abortion may be associated with a small increase in the risk of subsequent miscarriage or preterm delivery."
|"The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7",p 8-9, RCOG September 2004http://www.rcog.org.uk/index.asp?PageID=662|
|The RCOG advises with respect to abortion and mental health: "16.9. Psychological sequelae: some studies suggest that rates of psychiatric illness or self-harm are higher among women who have had an abortion compared with women who give birth and to nonpregnant women of similar age. It must be borne in mind that these findings do not imply a causal association and may reflect continuation of pre-existing conditions".||"The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7",p 8-9, RCOG September 2004http://www.rcog.org.uk/index.asp?PageID=662|
5.1 A recent study in New Zealand of women aged 15-25 who experienced a pregnancy, has been cited in political debate as definitive evidence that abortion and the development of psychiatric conditions are causally linked. However this view has no support from the authors of the paper, who acknowledge confounding factors that their research may not have accounted for. Under-reporting of abortion is a well-known problem with this type of research. In this study, the authors note a statistically significant difference between the rate of abortion in their sample and that of the general population.
There are other contextual factors associated with abortion-seeking to which the study could not be sensitive. The authors note: "It is clear the decision to seek (or not seek) an abortion following pregnancy is likely to involve a complex process" and that as a result, "it could be proposed that our results reflect the effects of unwanted pregnancy on mental health, rather than the effects of abortion per se, on mental health".
The comparator groups to participants who had an unintended pregnancy and then an abortion in this study, were women who stated that they had not experienced pregnancy and those who continued a pregnancy and became mothers. As the study was conducted in a context where abortion is legal, and available, it may be that the only group among these three groups of women who had experienced a pregnancy that was truly and consistently unwanted, were those who went on to have an abortion.
To properly attempt to explore the net impact of abortion in and of itself on psychological morbidity, the most valid comparator group to women who experience unwanted pregnancy and then abortion, is neither women who have not been pregnant, nor willing mothers, but instead women with an unwanted pregnancy who are denied abortion and then give birth. Such women, because legal abortion is available, were not able to be included in this study.
Fergusson DM, Horwood LJ, Ridder EM
"Abortion in young women and subsequent mental health"Journal of Child Psychology and Psychiatry. 2006 Jan; 47(1): 16-24.
5.1 To explore social outcome data on young women and abortion, 492 women participating in a 25-year longitudinal study of a New Zealand birth cohort were used in regression models that examined the relationship between pregnancy and abortion history prior to age 21 and selected social and economic outcomes at ages 21-25.
Results: Compared with young women who became pregnant before age 21 but did not seek an abortion, young women who had an abortion had significantly better outcomes on six out of 10 measures spanning education, income, welfare dependence and domestic violence. Adjustment for confounding factors indicated that most of these differences were explained by family, social and educational characteristics that were present prior to pregnancy. Nonetheless, even after adjustment for confounding factors, young women who had abortions had higher levels of subsequent educational achievement than those who became pregnant but did not have abortions.
Conclusions: Abortion may mitigate some effects of early unplanned pregnancy. However, further study of its potential risks and benefits is needed so that women can make fully informed decisions as to whether to terminate unintended pregnancies.
David M Fergusson, Joseph M Boden and L. John Horwood, "Abortion among Young Women and subsequent life outcomes". Perspectives on Sexual and Reproductive Health, March 2007, 39 (1): 6-12
|6. "3. Evidence of long-term or acute adverse health outcomes . . . from the restriction of access to abortion"|
6. Unintended pregnancy remains a serious public health problem in the UK. For some women, the right response when faced with this common problem will be to seek to end the pregnancy. It is important for the health of women to enable them to end a pregnancy safely and legally.
There are different routes to unintended pregnancy, but contraceptive failure and couples' imperfect use of contraceptives are an important factor. Unintended pregnancy rates differ between methods, and will depend both on how unforgiving of imperfect use a particular method is, and on how hard it is to use that method perfectly. Recent research from the United States shows that unintended pregnancy rates remain comparatively high, for example with male condom use, when studied according to "typical" use by couples. In this research, the "typical use" contraceptive failure rate has been explored as against the `perfect use' of male condoms, and other contraceptive methods.
With "perfect" use of male condoms, 2% of women will experience an unintended pregnancy within the first year of use. (eg Among couples who initiate use of this method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), this will be the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. But with "typical" use of male condoms, 15% of women will experience an unintended pregnancy within the first year of use. (eg Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason).
"Summary table of contraceptive efficacy: Percentage of women experiencing an unintended pregnancy during the first year of typical use and the first year of perfect use of contraception and the percentage continuing use at the end of the first year. United States".
From Trussell J. "Contraceptive efficacy".In Hatcher RA, Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D."Contraceptive Technology: Nineteenth Revised Edition". New York NY: Ardent Media, 2007.http://www.contraceptivetechnology.com/table.html
|6.1. Worldwide, there is little relationship between abortion legality and abortion incidence, but there is a strong correlation between abortion legality and abortion safety. 68,000 women die each year after unsafe abortion, of the 600,000 annual pregnancy-related deaths worldwide, according to the World Health Organisation. Many thousands of others are left with severe long-term health problems as a consequence.||
"Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000' Fourth edition
World Health Organization, Geneva, 2004.
|6.1. "An estimated 19 million unsafe abortions occur worldwide each year, resulting in the deaths of about 70,000 women. Legalization of abortion is a necessary but insufficient step toward improving women's health. Without skilled providers, adequate facilities and easy access, the promise of safe, legal abortion will remain unfulfilled, as in India and Zambia. [ . . . ] Timely and appropriate management of complications can reduce morbidity and prevent mortality. Treatment delays are dangerous, regardless of their origin. [ . . . ] While the debate over abortion will continue, the public health record is settled: safe, legal, accessible abortion improves health".||
"Unsafe abortion: the silent scourge"
British Medical Bulletin 2003; 67: 99-113
6.1. CEMACH's report, "Why Mothers Die" (2000-02) states of early pregnancy deaths that:
"the most striking change during the first 50 years of this report has been the disappearance of illegal, unsafe abortion as a cause of early pregnancy direct deaths which followed the passage of the Abortion Act in 1967.
The first Enquiry Report, covering the years 1952-54, described 153 deaths from `abortion', of which 108 at the least had been procured illegally. [ . . . ] Around 30 deaths per year from illegal abortion continued through the 1950s and 1960s. The first full working year of the Abortion Act was 1969 and the number of deaths `clearly due to illegal abortion', fell, that year to 17. [ . . . ]It is quite possible that the number of deaths from illegal abortions was underestimated.
The 1979-81 Report noted that the number of deaths attributed to spontaneous miscarriage had decreased from 1970, in parallel with those from illegal abortion.
"For data see Figure 6.1 "Maternal mortality rate from all maternal deaths from miscarriage (embryonic deaths) and terminations of pregnancy; England and Wales 1952-84, and United Kingdom 1985-2002" for data
James Neilson writing on behalf of the Editorial Board,
CEMACH, Chapter 6: Early Pregnancy Deaths, "50 years ago ...",
in "Why Mothers Die 2000-2002 (Full report) p 102, http://www.cemach.org.uk/getdoc/0dd34f16-5488
Figure 6.1 "Maternal mortality rate from all maternal deaths from
miscarriage (embryonic deaths) and terminations of pregnancy; England
and Wales 1952-84, United Kingdom 1985-2002", in "Why Mothers
Die 2000-2002 (Full report)" p 103,http://www.cemach.org.uk/getdoc/0dd34f16-5488-4c85-
|6.1. In 2005, the Department of Health produced a partial regulatory impact assessment of the "Prohibition of abortion (England and Wales) Bill". This Bill had the main intention of prohibiting abortion except where the woman's life was at risk, or if the pregnancy resulted from rape. The Department found that a restriction of this nature would be likely to bring about "a high risk of up to 15 deaths a year, 15,000 extra teenage mothers a year, and 12,000 children a year neglected/abused".||Department of Health, "Summary Costs and Benefits Table",
in "Partial RIA: Prohibition of Abortion", 2005.http://www.dh.gov.uk/prod_consum_
6.5. 53% of 729 respondents attending Brook Advisory Centre's sexual health services who were aged between 12 and 25 and "who gave a single answer as requested, said that confidentiality was the single most important thing for them when they were seeking sexual health advice.
The next most popular answer was `not being judged by anyone', accounting for 19% of responses, closely followed by `that it is free', which was the answer chosen by 18% of respondents.
The findings suggest that confidentiality is particularly important for young people under the age of 16. 62% of this age group said that confidentiality was the single most important thing for them. 18% said not being judged was the most important thing for them, and 14% said that the fact the services were free was most important".
|Brook Advisory Service, "Wise Up" survey, 2005.http://www.brook.org.uk/content/M6_3_
|6.5. Restrictions on the right of Gillick-competent young people to receive abortion and contraceptive care after a confidential discussion with a healthcare professional would have an adverse effect on their health. In fact most young people in any case involve their parents, another adult and their partner (in many cases all of the above) in discussions of this kind. The abortion provider MSI surveyed 108 clients aged under 16 between 18 April and 17 July 2005. They found that 79% of clients "had informed a parental figure", and a further 21% had told a friend or sister, (some of whom would be likely to be over 18) potentially adding to the 79% of informed adults. 94% of respondents were accompanied to the centre of the day they completed the questionnaire.||Marie Stopes International, "Abortion and young women: issues of confidentiality" 2005.http://www.mariestopes.org.uk/uk/publications.htm]|
6.5. A small survey carried out by BPAS aimed to discover the extent to which young women aged under 16 were, or were not accompanied to BPAS for consultation on pregnancy options, and were, or were not accompanied to BPAS for abortion treatment. If accompanied, some details were given about their escort(s).
Method: in a two week period in August 2007, BPAS Consultation centre staff spoke confidentially and anonymously to all BPAS clients aged under 16 and then completed a questionnaire noting the presence of their escort(s), if any, whether the escort(s) were aged under or over 18, and the escort(s) relationship to the client. 51 escorts were surveyed.
Result: Responding centres found that no client aged under 16 had attended her appointment alone for consultation, or for treatment. The most frequent escorts were the client's parents, 55% of escorts at consultation being the client's mother or father, and 45% of escorts being the client's mother or father at treatment. 56% of clients overall attended their BPAS appointments with their mother, whether or not also accompanied by additional escorts.
At consultation appointments, 80% of the 20 surveyed clients' escorts were adults aged over 18, and at treatment appointments 74% of the 31 surveyed escorts were adults aged over 18.
At consultation appointments, 3 out of 16 (20%) of clients were solely escorted by someone aged under 18. At treatment appointments, 2 out of 25 (8%) of clients were solely escorted by a person aged under 18.
|"Snapshot survey of BPAS clients aged under 16 years old at Consultation and Treatment:Is the client accompanied by an escort, and if so, by whom? ", 2007|
It is difficult to draw firm conclusions from a survey of this size, but these results accord with BPAS' experience that when young women come for advice or treatment they are nearly always supported by a family member or other adult, except where this is not possible usually due to the nature of relationships within the family.
Note: As staff were recording all activity involving clients under 16 years old, one case was submitted which does not fall within in the survey parameters, but which is included here for interest. An under 16-year-old attended a BPAS consultation centre for counselling on pregnancy options but did not in fact receive this. This was because the routine ultrasound scan at her visit showed the pregnancy to be beyond 24 weeks' gestation. She was therefore referred into antenatal care, in accordance with the law.
Empirical evidence from BPAS shows that for clients to present close to the legal abortion limit for pregnancy counselling is rare, but not unknown. Late presentation is comparatively more common within the younger client age group. Recent research from the University of Southampton supports this.
|"Women under 18", in "Second-Trimester Abortions in England and Wales" by Roger Ingham, Ellie Lee, Steve Clements, and Nicole Stone, 2007, (p.3) http://www.soton.ac.uk/lateabortionstudy/late_abortion.pdf|
|6.7. The Department of Health's advice to the public on unregistered counselling is: "There are a number of organisations advertised in phone directories and on the internet offering free pregnancy testing and counselling. Some of these organisations do not refer women for termination of pregnancy. We would advise women to check this before making an appointment".||
UK Department of Health, "Register of Pregnancy Advice Bureaux",
1 August 2007. http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/
|6.7. The practices of "Crisis pregnancy" centres (CPCs) and their numbers have not been well-researched in the UK, and BPAS is not aware of published evidence concerning them. However, a body of evidence exists upon the need for patients to make free and informed decisions about their medical care, and of increased risks to women's health posed by unnecessary delays to abortion or antenatal care.|
6.7 The websites of some of the UK's "Crisis Pregnancy" organisations show a variety in the quality of information that is provided by some on the risks posed by abortion. To give one example from one such organisation, the "Care Confidential" website offers information to the public on abortion.In the section "What are the health risks?" "Care Confidential" states:
"[ . . . ] There have been suggestions that abortion is linked to breast cancer".
While it is of course true to state that suggestions about this link have been made in the past, this link has not been supported by evidence. The RCOG's factsheet "About abortion care: what you need to know", offers patients clear and unequivocal information on this.
Under the section "How safe is abortion?", the RCOG has the question "Does abortion cause breast cancer?" and it answers: "Research evidence shows that having an abortion does not increase your risk of developing breast cancer".
The standard RCOG guidance to healthcare professionals states under recommendation
"2.2: Information for women", "Recommendation 16: Clinicians providing abortion services should possess accurate knowledge about possible complications and sequelae of abortion. This will permit them to provide women with the information they need in order to give valid consent".
Some examples of relevant medical information for women are then given, including:
"16.7 `Breast cancer: induced abortion is not associated with an increase in breast cancer".
Care Confidential (website):"What are the health risks?" in "Your questions answered: What about abortion?"http://www.careconfidential.com/WhatAboutAbortion.aspx(accessed on 30 August 2007)
RCOG Information for patients:"Does abortion cause breast cancer?",
within "How safe is abortion?" within "About abortion
care: what you need to know",
RCOG information for professionals:"2.2 Information for women",
within "Summary of Recommendations, p 8, "RCOG Care of women
requesting induced abortion", 2004,
|"Care Confidential" is a department of CARE, a Christian charity. "Care Confidential" offers a national phoneline, web-based counselling and refers women to local crisis pregnancy centres for face-to-face advice. Care Confidential does not refer women for abortion and is not on the Department of Health Register of Pregnancy Advice Bureaux.|
6.8. The quality of information given to women about mental health and abortion by some of the "Crisis Pregnancy" Centres websites seems to vary. for example, the website of the "Norwich Pregnancy Crisis Centre" ("PC-N") states that:
"Post-abortion stress is an increasingly recognised condition affecting at least 10% of women who have had a termination.In Norfolk, current statistics suggest that around 180 women each year are in need of support. [ . . . ] The effects of post-abortion stress can include depression, anger, emotional numbness, eating disorders, relationship difficulties, remorse, anxiety, or a sense of isolation. [ . . . ]At present post-abortion stress often goes undiagnosed, so PC-N also offers training to health professionals to help them recognise the signs of this condition. PC-N has recently secured funding over three years through the [local NHS PCT] Health Development Fund to continue and develop this aspect of its work".
|From the website of the "Norwich Pregnancy Crisis Centre"/ "Pregnancy CrisisNorfolk",Under the section "Post-abortion stress "http://www.pregnancy-crisis.org.uk/(accessed 30 August 2007)|
6.8. BPAS is concerned that in some local areas, unregulated Crisis Pregnancy centres appear to have received funding support from local NHS Primary Care Trusts and appear to be permitted to "train" doctors in local NHS hospitals on conditions such as "Post Abortion Stress" which are not professionally recognised.
One example of this could be the Norwich Pregnancy Crisis Centre (NPCC), which appears in Norwich PCT's "Health Development Fund 2004-05End of Year Report". Under "Projects that have service level agreement commitments into 2005-06", they record under "Budget Position", "First year funding paid (£9,000) [to Norwich Pregnancy Crisis Centre]"
[ . . . ] also,
Norwich PCT Health Development Fund 2004-05End of Year Report, p 12,
"As [NPCC] have trained four more counsellors they have spare capacity and could see more clients, NPCC are actively approaching GPs and other health professionals in order to offer training courses on post-abortion stress. Often post-abortion stress goes unrecognised and the training equips health professionals to more easily pick up those patients who could benefit from support. The Health Development Fund has enabled NPCC to continue to offer pregnancy loss counselling within the Norwich area and to increase the understanding of health professionals about post-abortion stress".
Norwich PCT's "Health Development Fund 2004-05End of Year Report" then goes on to record that NPCC has made a "Presentation to 10 health professionals, including GPs and practice nurses" and notes that: "A big boost has been made by liasing with the medical school at UEA where arrangements have been made to train Year 4 medical students on post-abortion stress, which will no doubt be helpful regardless of where these future doctors work".
|Norwich Pregnancy Crisis Centre website:
(accessed 30 August)
6.9. The Irish Family Planning Association has produced a paper called "Rogue Crisis Pregnancy Agencies in Ireland", which states:
"The IFPA believe that the Government should bring forward statutory regulation for all pregnancy advice and counselling services, prescribing minimum codes of practice and standards, to ensure that they do not impart misleading and incorrect advice. In addition, it should be mandatory for all services to register with a recognised authority".
"Legislation for RCPA's", (p 6), in "Rogue Crisis Pregnancy Agencies in Ireland", published by the Irish Family Planning Association
6.9. In the Republic of Ireland, the statutory Crisis Pregnancy Agency was established in October 2001, with functions including :
"... the promotion of state-funded crisis pregnancy counselling services to tackle the problem of "rogue counselling agencies".
The Agency developed a highly visible Positive Options press campaign, highlighting that the services promoted under Positive Options were statefunded, non-judgemental and trustworthy.The Manual of Good Practice for Crisis Pregnancy Counsellors was completed in 2006.
The Agency began work with NUI Maynooth on the development of a new, accredited course in crisis pregnancy counselling skills. Our research shows that a woman with a crisis pregnancy needs to be able to access support services in her local area. The expansion of counselling services was thus a priority for the Agency in 2006 and will continue to be a priority in the years ahead".
"Introduction and Overview of 2006 by the Director", in the "2006 Annual Report of the Crisis Pregnancy Agency Ireland". (p 5)
|6.9. The National Abortion Federation (USA) produced a report on American and Canadian Crisis Pregnancy Centres in 2006, which provides documentation as to the barriers to healthcare that may be experienced a result of unregulated services and the remedies in several states that have been taken to enforce the "clear labelling" of such services.||
National Abortion Federation, "Crisis Pregnancy Centers: An Affront to Choice", 2006
|© Parliamentary copyright 2007||Prepared 15 November 2007|