Examination of Witnesses (Questions 140-157)|
15 OCTOBER 2007
Q140 Mrs Dorries: Do you believe
that abortion in itself increases the risk of subsequent premature
births? If so, do you think that if that is the case again the
RCOG guidelines should be updated to inform women that this is
the case along with everything else that they are not informed
Dr Richards: I do believe so.
I think we have seen in the previous session that the evidence
is substantial. There are over 49 articles now, studies, showing
an association between prematurity and preterm labour in subsequent
pregnancies and a woman having had an induced abortion. It is
widely respected in the literature that there is an association.
We also have potential causal explanations for why there is an
association. The actual process of the induced abortion itself
may weaken the cervix. It is conjectural but there are potential
explanations for why there should be an association between induced
abortion and preterm labour. As Professor Wyatt did say, it is
interesting that there is what we call a dose relationshipi.e.,
the more induced abortions that a woman has experienced, the more
likely preterm delivery is going to be in the subsequent pregnancy.
Q141 Chairman: Could I ask for other
views, please, from the panel?
Professor Norman: Again, I am
surprised at what you say about the RCOG guidelines because I
have them in front of me and they say that
Q142 Mrs Dorries: I have read them
Professor Norman: In your advice
to women, they say that you should say there may be an increased
risk in preterm delivery in association with abortion.
Mrs Dorries: Do you not think the RCOG
play that down slightly though? I think it is a very important
factor for a woman, along with other factors when seeking an abortion,
that she is given all the information pertaining to that request.
Having been with two teenage girls whilst they requested abortions
as part of my own work into a Bill, that has not happened. Nothing
that was laid down in the RCOG guidelines was explained to the
girls when they went for their terminations. That is why I think
maybe they should be beefed up slightly.
Chairman: That is a different issue to
the RCOG guidance itself, is it not?
Mrs Dorries: I think it needs to be stronger.
Q143 Chris Mole: Can any of our clinicians
with experience suggest whether there is likely to be a difference
between a medical abortion and a surgical abortion? If, as Professor
Wyatt suggested earlier, there is an increase that is related
to infection and cervical damage, is that reduced by the use of
chemical induced abortions?
Dr Richards: I would be very happy
to answer that. There was a pertinent study recently in The
New England Journal of Medicine which compared medical and
surgical abortions over a period of time. Its premise was that
surgical abortions did not have a higher risk of any of these
complications, including preterm delivery. It said that the rates
following medical abortion were similar to those following surgical
abortion. If the premise were correct, which I do not believe
it is, then it is true that medical abortion would also be safe.
If surgical abortion is dangerous and has the complications we
have talked about
Q144 Dr Harris: Can I have a consensus
from the panel? Do we agree or not that all people involved in
counselling women for abortion should be registered and regulated
in the UK or England with the Department of Health? Does that
seem reasonable? Then they can have quality control over what
they have said.
Dr Rowlands: I would support that.
Q145 Dr Harris: Dr Richards?
Dr Richards: Can you repeat the
Q146 Dr Harris: Do you think that
all people providing this information, whether it be doctors or
counselling organisations, should be registered and therefore
regulated for quality in the content, whatever it is, by in England
the Department of Health?
Dr Richards: Do I believe that
a GP who knows the woman best when she approaches for induced
abortion should be registered and regulated in the advice that
Q147 Dr Harris: They are by the GMC.
I am just talking about counselling organisations.
Dr Richards: This is all part
of a general practitioner's work.
Q148 Dr Harris: I am talking about
other people involved because, as you know, there is counselling
offered when people come for abortions. I would like to ask the
rest of the panel whether they think that is reasonable.
Professor Norman: I think it is
important that women are given appropriate, unbiased advice. Whether
that is best achieved by regulation I do not know.
Dr Lee: I agree with that. Also,
I really think that the RCOG and its committee which came up with
the guidelines on induced abortion updated in 2004 are not being
given a fair enough hearing here. Mrs Dorries is wanting to make
the point that what is said in the evidence is not strong enough.
The point about the RCOG guidelines which I find very compelling
in the process through which they were generated was a very careful
process of reviewing the evidence as a whole, taking into account
everything that has been published in respected journals and trying
to present a balanced account of the sum, rather than emphasising
what comes out of particular studies. As a result, it is going
Q149 Chairman: We are going to have
the Royal College in front of us. I would like, particularly from
Professor Norman and Dr Richards, an answer to this fundamental
question about the health risks to women as a result of abortions
and how you assess those health risks.
Dr Richards: I believe you assess
those health risks with individual studies that look at the various
different indices that you are concerned about. You have had evidence
presented to you about the risk to psychological, psychiatric
health. You have had evidence about the risks of subsequent preterm
delivery and you have had evidence about breast cancer. I found
that collection of studies very powerful.
Professor Norman: We have discussed
psychological sequelae and I do not want to rehearse those arguments
again. I would agree there may be an increased of preterm birth
associated with induced abortion. We know how we can reduce those
risks by treating women earlier. We know that if women have abortions
earlier they are less likely to have cervical damage which may
lead to preterm birth. If they have their abortions done by people
who are expert, again that reduces that risk. I would entirely
disagree with you about breast cancer. I think the evidence is
compelling that there is no increased risk of breast cancer in
association with either induced abortion or miscarriage. There
was a very big study done by an Oxford group which was published
just at the same time as the RCOG guidelines. They looked at 83,000
women with breast cancer and found no increased risk of breast
cancer in women who had had abortions compared to women who had
not been pregnant. This view is also endorsed by the American
Cancer Society that says the level of evidence about the lack
of association between breast cancer and induced abortion is grade
one, so that is the best evidence you could possibly get. The
American College of Obstetricians and Gynecologists also endorses
Dr Rowlands: I said in my submission
that the risk of preterm birth and miscarriage appears to be associated
with induced abortion. There are data on that but, as Professor
Norman has said, we need to look at things like cervical priming
as to how we can reduce these risks. At the moment it seems like
medical abortion is very safe but we need more studies on medical
abortion because without the instruments it would appear less
likely that there would be any mechanical damage to the neck of
the womb, but obviously we need more studies on that.
Q150 Mrs Dorries: Dr Evan Harris
asked Professor Caseyand she answered the questionwhether
or not she was pro-life. Dr Lee, are you pro-choice?
Dr Lee: Yes.
Q151 Dr Turner: Out of the women
who ask for abortions, do they always fulfil ground C of the Abortion
Act, meaning that the continuance of pregnancy would involve risks
greater than if the pregnancy was terminated or of injury to the
physical or mental health of the pregnant woman? Is that piece
of law satisfied by most women who apply for an early abortion?
Professor Norman: Yes, I would
Q152 Dr Turner: Does everybody agree
Dr Richards: I do not agree with
it. It is rarely fulfilled.
Q153 Dr Turner: Can you say why?
Dr Richards: Because I think the
risks of mental health and physical damage to the woman following
abortion are substantial and greater than if they continue to
delivery. I believe that that ground is rarely fulfilled and is
wrongly interpreted by most practitioners in this country.
Professor Casey: I cannot comment
on it in relation to physical illness. I can only comment on it
in relation to psychological illness and it certainly is not fulfilled.
Dr Rowlands: I think it is fulfilled.
Q154 Dr Turner: We do not have a
unanimity of view. Do medical abortions carry a similar risk or
greater risk than surgical abortions?
Dr Richards: We have already mentioned
a paper in The New England Journal of Medicine which I
think many of us are aware of. I believe it is a Danish study
where they looked at the complications of medical and surgical
abortion over a period of time. It tells us nothing about the
absolute incidence of the complications, such as ectopic pregnancy
and preterm delivery, but it does give us some indication about
the comparison between the two. Largely speaking, the complications
are at the same rate between a medical and a surgical abortion.
If the premise is that surgical abortion is safe, you might assume
that medical abortion is safe but if you do notas we have
seen evidence for herethen we cannot make that assumption.
Q155 Dr Turner: Would anyone like
to comment on the death rates in the first year following an abortion?
Dr Richards: It is pertinent to
medical abortion that there has been a group of people who have
died suddenly following medical abortion. It is a rare infection,
clostridium sordelli, and it has probably killed five or seven
people in America and Canada. This is very early days to know
how frequent that infection is going to be. What was striking
was how difficult it was for the doctors looking after these patients
to diagnose it. It was very hidden. They did not have fever; they
did not have rash and then they suddenly died. It is much too
early to assume that medical abortion is a safe means of abortion.
Q156 Mrs Dorries: Rosie Winterton
in reply to a parliamentary question responded that there had
been two deaths this year in this country from the same thing.
Dr Rowlands: On the Clostridium
Sordelli, yes, there was one death in Canada in a trial in 2001.
There were five deaths in the US between when the mifepristone
was launched in 2000 until the present time. During this time,
during childbirth, there have been eight cases. The Centers for
Disease Control and the Food and Drug Administration had a meeting
in May 2006 and unfortunately there is very little information.
They agreed to increase surveillance and detection of cases but
the point is that death from this condition is rarer than death
from anaphylaxis after being given a shot of penicillin. In the
US during that time, where those deaths happened, there were 600,000
medical abortions. In Europe there were many hundreds of thousands.
The only cases that are recorded are one in Canada, four in California,
which is peculiar and no one has been able to explain that, and
one in a western state of the USA but nowhere else in the world.
Dr Richards: The New England
Journal review following that article said that it may mean
that death from infection from medical abortion is ten times greater
than surgical abortion. In other words, they considered that it
was a significant observation and may be, but as yet unproven,
a substantial risk from medical abortions. We have to be very
cautious to say what "safe" means in this content.
Professor Norman: The RCOG guidelines
have come in for some criticism so I think I should say in their
defence that, in this particular situation, they do advise that
women are screened for particular infections when they have terminations
of pregnancy, including Chlamydia, and that antibiotics given
prophylactically to women having abortion, both medical and surgical,
to minimise the risks of these adverse outcomes.
Q157 Dr Harris: Can I ask the representative
from the Royal College whether you consider medical abortion to
be a satisfactorily safe procedure? We know nothing is ever completely
safe; walking down the street is not safe.
Professor Norman: I certainly
have not seen anything that makes me think it is not safe. One
of the difficulties is we have only been doing medical abortions
for, what, ten years, so data is still accumulating. From what
we know about the way that medical and surgical abortions are
done, it seems to me likely that they will be at least as safe,
if not safer than, surgical abortions.
Chairman: On that note, could I thank
Professor Casey for coming from Dublin today, Dr Ellie Lee, Professor
Jane Norman, Dr Chris Richards and Dr Sam Rowlands for your patience
with the Committee? Thank you very much indeed for your evidence