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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