Select Committee on Science and Technology Minutes of Evidence


Examination of Witnesses (Questions 68-79)

PROFESSOR PATRICIA CASEY, DR ELLIE LEE, PROFESSOR JANE NORMAN, DR CHRIS RICHARDS AND DR SAM ROWLANDS

15 OCTOBER 2007

  Chairman: Good afternoon to our second panel: Professor Patricia Casey, professor of psychiatry at University College, Dublin, Dr Ellie Lee, lecturer in social policy at the University of Kent, Professor Jane Norman, honorary consultant obstetrician and gynaecologist at the University of Glasgow, Dr Chris Richards, consultant paediatrician at the Royal Victoria Infirmary, Newcastle upon Tyne, and Dr Sam Rowlands, a visiting senior lecturer at the Warwick Medical School. Welcome to you all. You have seen from the first panel how kind my Committee is in terms of questioning.

  Q68 Graham Stringer: Dr Lee, last year there were about 3,000 abortions between 20 and 22 weeks and fewer than half of those were between 20 and 24 weeks. Why are there so many late abortions in this country?

  Dr Lee: Those figures are not quite right. If you take the entire 20 to 24 week band, it is about 1.5% of terminations which comes at about 2,500 terminations, unless I heard you wrong?

  Q69  Graham Stringer: The figures I am briefed on are 2,948 20 to 22 weeks and 1,262 22 to 24 weeks which are 1.5% and 0.7%.

  Dr Lee: I suppose it depends what you think is a large number. The proportion of terminations at 22 to 24 weeks has remained the same. It is one of the important points that I was trying to emphasise in the evidence I submitted to the Committee. If we look at where there has been a significant shift over the past five years in the temporal patterning of abortion, it is in the first trimester. One of the things that is testament to is the import of policy intervention in this area because policy intervention does appear to have shifted the temporal patterning of gestation from the latter end of the first trimester into earlier in the first trimester, which is a significant gain in public health terms because there is wide agreement that earlier abortions are better than later ones. In terms of the data that we have, if we look at the gestation band 20 to 24 weeks, it has remained remarkably consistent over the years. It was to try and look at the issue of remarkable consistency and more widely also the earlier aspect of second trimester abortion, so 13 to 20 weeks. That was why we conducted the study that we did and why I thought it was important for the Committee to see the evidence that there is on this. If we take the latter end of the second trimester band, the most important factors which have emerged from the available research about this are what distinguishes women in that band from women earlier in the second trimester. That is to say, if you compare 13 to 17 weeks with 18 weeks in and above. The two main factors that stand out are, first of all, a particularly high propensity for women at 18 weeks in and above to experience delay at the point of referral. There is a significant issue here in terms of service provision for the whole second trimester band but it particularly pertains for 18 weeks and over. Women reported more frequently delays at that gestation band than at the earlier stage of the second trimester. The first clinician they consulted either made it difficult for them to proceed and to be referred on or did not know where to refer them. There is both an issue of GPs not liking women requesting abortion at this stage and therefore creating difficulties in terms of further referral or not knowing where to send them, which I think relates to the broader issue of the reconfiguration of abortion services in the late second trimester which we can discuss if we want to. The second factor which I was very struck by in particular from the study that I worked on with colleagues from Southampton University was that more than half of women who were 21 weeks and over reported that they did not perform a pregnancy test until they were at least 18 weeks and two days pregnant. That is to say, the women did not actually confirm the pregnancy until they were more than 18 weeks pregnant. That is the 21 weeks and above band. What this suggests is a combination of late recognition of pregnancy. For women at this stage of late referral for abortion and late seeking of abortion, they do not recognise they are pregnant. Often it is because they have continued bleeding which they interpret as a sign of continuing periods. That is one issue. The other issue is that for a lot of women who terminate pregnancies later on it is associated with ambivalence and difficulties with coming to terms with all of this. Sometimes women do not want to do the pregnancy test because that means you have to face up to all of this. These areas and particularly this question of ambivalence are very difficult to find a straightforward resolution to. Ambivalence in deciding what to do about an unplanned pregnancy is part and parcel of what unplanned pregnancy is all about, the experience of it. I think it would be a very negative step to try and push these women into making a decision about all of this but it is a significant factor in explaining why later terminations occur.

  Q70  Graham Stringer: In the studies you refer to what are the demographics? Are there any differences in the socio-economic background of the women?

  Dr Lee: The only study which has looked at that was the one I was involved in. There are very few studies for this country looking at why women have late abortions. To my knowledge, apart from the one that I was involved in, there are only two others of any significant size. There is some American data but that is all there is. In the study that we were involved in, we had returns from 883 women so it was a relatively large sample size for studies of this kind. Just over 100 of those women we could not get the information for but as far as we could we matched the returns with measures of socio-economic background. Interestingly, there were almost no correlations. There was a small, negative correlation between difficulty in the women making her mind up and socio-demographic information. That is to say, women from lower socio-economic groups appeared to find it easier to make the decision but I definitely would not want to make too much out of this because the overriding message when we correlated these sets of data was that there were no significant correlations. Age was important however.

  Q71  Graham Stringer: Can you explain to the Committee what the correlation was?

  Dr Lee: It is a well known observation on the part of people who provide abortion services that it tends to be the case relative to women seeking abortion within particular age bands that women who seek abortion at later gestational stages tend to be younger. These data often are really misrepresented so people think that most women having late abortions are teenagers. That is not true. Relative to the age band, there is a high proportion of teenagers who have abortions late. In our study what emerged about all of this is that younger women reported later recognition of pregnancy so they just did not realise they were pregnant; difficulties in communicating with others about it, particularly with parents, so they hid the pregnancy; concerns about what abortion involved which meant they delayed requesting a termination of pregnancy. Older women in contrast were more likely to report than the younger women difficulties in deciding to have an abortion related to issues to do with relations with their male partners.

  Q72  Graham Stringer: Has the work that you have been involved in been peer reviewed?

  Dr Lee: At the moment we have one article submitted which is being peer reviewed and we are writing another currently. The reason I submitted the document that I did—and it may be my misreading of the advice given to people potentially submitting evidence—is one of the things you said in the guidelines was that you did not want already published evidence. I therefore assumed that the Committee would like insight into newly completed studies. At the moment we are submitting papers and they are undergoing the peer review process. The entire methodology is publicly available though, the complete report with methodology.

  Q73  Graham Stringer: Are there any regional correlations in the patterns of women presenting for late abortions?

  Dr Lee: That was not something which our study detected. The study was based around quite deliberately primarily British Pregnancy Advisory Service clinics and two other independent sector clinics. The reason we did this was because we wanted to be able to find out evidence about the population group of women seeking particularly late abortions. About 80% of those abortions at 20 weeks and over are carried out by the British Pregnancy Advisory Service. What happens is that women attending these clinics for later abortions come from all over the place because there are now so few NHS facilities providing these late abortions. It makes it quite difficult, on the basis of the kind of information we were collecting, to come up with any kind of sensible correlations about geography. The one thing that is clear though is that women presenting for late abortions often have to travel a long distance for their consultation appointment and for the procedure.

  Q74  Dr Turner: Other countries in Europe have much lower abortion limits than us. Can you comment on that and in particular how they deal with the obvious problem that was highlighted by the previous set of witnesses, that in many cases abnormalities and potential disabilities are not detected until 22 or 23 weeks?

  Professor Casey: I am not sure I can answer that because abortion is not legal in Ireland. Women come to Britain for abortion. The numbers coming peaked in 2001 and since then have declined significantly. The raw number coming in 2001 peaked at 6,700 and the figures for 2006 were 5,043, so there has been a big reduction. We do not know why that is exactly. It has been speculated that they are perhaps going to Amsterdam on the cheap Ryanair flights that we all hate using but are forced to sometimes. In fact, the Dutch figures are not showing that up because that has been checked. We think there is a genuine diminution in abortion in Ireland because we have constant abortion debates in Ireland so young women will be much more familiar with the issues. Many of them will be very familiar because we have had television programmes about the 4D imaging that will have changes some women's attitudes. That is the situation in Ireland. I cannot really comment beyond that.

  Professor Norman: Just because abortion is illegal in a country does not mean it does not happen. If you look at Latin America, for instance, their abortion rate is 30 to 60 per thousand women of reproductive age compared to ours of about 15, although abortion is illegal in Latin America. You cannot entirely correlate the occurrence of abortion with the legality of it in other countries.

  Q75  Dr Turner: We have already heard that one of the factors in late abortion is indecision on the mother's part. Do you think that having a limit like the German limit of 13 weeks sharpens the mind? Do you think that German women, as a result of the 13 week limit, are more decisive?

  Dr Lee: I have never seen any studies which do or do not sustain that proposition. People talk about European abortion laws. Europe has a whole range of different sorts of abortion laws. The law in the Netherlands is extremely liberal. The same holds for Sweden, but not for France, Germany. They are very different. The one thing we do know is that jurisdictions which have stricter controls around second trimester abortion generate abortion tourism. Lack of access to all sorts of reproductive health services creates tourism. Women travel to other countries. We know there is an inflow of women for example from France to this country for second trimester procedures. In relation to whether lowering of the limit sharpens women's minds, I think that is pretty unlikely. Thinking about the study that I have been involved in, more than 50% of the women in the sample as a whole reported that they did not first request an abortion until they were more than 13 weeks pregnant. That is to say, they were already out of the first trimester band. The explanations that they gave for these things do not seem to me to be ones which would be affected by the abortion law, the fact that they were using contraception so it did not even enter their heads that they would be pregnant or if they had breakthrough bleeding and misinterpreted that as periods. These things do not seem to me to be things that would be changed by a reduced upper limit, but I have never seen a study which has investigated the point you have just raised.

  Q76  Dr Turner: You do not think that lowering the limit would encourage women to present earlier?

  Dr Lee: No. What lowering the limit would do would be to create traffic to countries which had a different limit or women would have to have the babies. That would be the outcome. I do not think it would make women present earlier. It is a shame Kate Guthrie is not on this panel because she sees women, but I see no reason from research that I have been involved in to imagine that.

  Q77  Dr Turner: Can you think of any medical or social reasons why the UK should be relatively unique in Europe in having a 24 week limit as opposed to the lower limits in other countries? Are there any unique factors in the UK?

  Dr Lee: I could deliver an entire paper on this. My suspicion is it is probably outside the remit of this particular Committee but there are all sorts of very interesting issues surrounding the evolution of abortion laws in different jurisdictions. One point to bear in mind about the 1967 Act in this country is that Britain was the first country of the ones that you are talking about to legalise abortion. It happened in a very particular context. The legalisation of abortion in this country was the product of a particular set of social influences. The thing that is striking about the British abortion law is that it has the highest upper limit. As we know—people always make this point about other jurisdictions in Europe as well—it does not permit abortion on request at any stage. In one sense it is both the most conservative and the most liberal if you see what I mean, which is a very interesting phenomenon about this law compared to other jurisdictions. If you look at other jurisdictions, because they were subject to different sociological and historical factors, most of these reforms were passed in the 1970s. That explains the difference in them but that is really a question of history and sociology.

  Q78  Dr Turner: To your knowledge, are you aware whether in other countries late abortions for what would be in this country considered good, medical reasons do actually occur?

  Dr Lee: Yes, I think they do. I think women just go to other places to get them.

  Q79  Dr Turner: Do they occur in country?

  Dr Lee: In countries where for example after 13 weeks abortion is only permitted on grounds where there is foetal abnormality, women would travel. That is my presumption but I am not an expert on abortion practice in Europe.


 
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