Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 220-239)


17 OCTOBER 2007

  Q220  Chairman: It was purely opinion?

  Dr Calland: Yes, it was opinion. Conference debates do not always follow evidence.

  Dr Harris: That is very reassuring.

  Q221  Dr Turner: You are probably going to say that there is not any evidence but is there any suggestion that a change in location might affect the psychological impact on the patient, perhaps the lack of support?

  Dr Calland: I cannot give a BMA line in answer to that question because we really just do not have one. You can draw all kinds of personal conclusions but they are not representative of the BMA as a whole.

  Q222  Dr Turner: Dr Argent, as a clinician, do you have a view?

  Dr Argent: Indirectly yes because there is evidence that services are better, there is a better outcome, if there is a good robust follow-up service and access to a help line. Many of those facilities are not available in other premises. They tend to be available in some of the private charitable providers and some NHS clinics but by and large in general practice that would not necessarily be the case.

  Q223  Dr Turner: It has been suggested that there might be an advantage in terms of increasing the capacity of abortion services and therefore ensuring that women get a better opportunity for an earlier abortion if it was allowed in the home. Is that a widely held view in your experience? Do you see any virtue in it?

  Dr Argent: I am not sure about the question of whether that applies to being unhappy with the procedures at home but the general section on health strategy is to make services more accessible.

  Q224  Dr Turner: A wider range of facilities could be useful?

  Dr Argent: I am not sure about that.

  Q225  Dr Turner: I thought that was what you were saying. So you are not certain on that. If the range of settings in which abortions can take place were to be increased, including possibly the home, what sort of support frameworks do you think would need to be put in place to ensure both patient safety and psychological safety and so on?

  Dr Argent: For patient safety there needs to be a comprehensive advice service and back-up service with access to clinics that can see the patient fairly soon. That would mean having access at night and during the weekends.

  Q226  Dr Turner: And perhaps an outreach service as well?

  Dr Argent: Yes.

  Liz Davies: I think we have to approach this with some caution because we have to look at the organisation of services and the sheer scale of abortion numbers in the UK and the fact that specialist providers are able to accommodate women very quickly and very speedily—I am not sure that would happen if it was totally deregulated—and also that we have the back-up services in place, 24 hour help lines. I feel that the NHS would be absolutely swamped and not be able to cope if the situation changed.

  Q227  Chairman: But, Liz, does not Marie Stopes have a policy of giving misoprostol for women to take at home?

  Liz Davies: No, we are not allowed to do that. Both medications, both the mifepristone and the misoprostol, are actually taken on the premises but the women do go home immediately afterwards to undertake the actual process at home, but they have to take the actual medication on our premises.

  Q228  Chairman: The risk of a woman taking misoprostol on your premises and then actually having a miscarriage on the bus going home is a real possibility. What is the advantage of doing that over taking the misoprostol at home? That happens in other countries. Is there any evidence that that is a safer process for the woman concerned?

  Liz Davies: Certainly we do counsel the woman very carefully. We talk to her about how long it is going to take her to travel home. We do tell her about the side-effects of the medication, what could possibly happen. We usually find that the actual miscarriage following misoprostol will take place usually three to four hours afterwards, and so we ensure that women do have sufficient time to get home before that happens. We give our clients the choice. Most of them, about 95%, will choose to go home to undergo the process following the medication.

  Q229  Mrs Dorries: Can I ask you why you describe this process as a miscarriage and not an abortion, which is what it is?

  Liz Davies: Basically it is an induced miscarriage. Yes, it is an abortion, a medical abortion.

  Q230  Mrs Dorries: It is an abortion?

  Liz Davies: It is. It is an abortion.

  Q231  Mrs Dorries: I would say it is misleading to describe it as a miscarriage.

  Liz Davies: The methodology of that particular nature of abortion does induce miscarriage, so even though, yes, it is an induced abortion, it also induces miscarriage of the foetus. It is not removed surgically.

  Chairman: I was not trying to mislead the committee by saying that. It was the terminology you have used in your evidence.

  Q232  Mrs Dorries: Could I ask you about a woman having a miscarriage on a bus and going home. We know the process of both of these drugs, whether the drugs are taken at home or in the clinic, induces excruciating uterine pain, perhaps because the uterus is contracting on a very small substance within the uterus. Do you think it is appropriate that 16, 17 and even 15 year old girls are sent home in such pain to deal with this procedure at home and deal with the amount of bleeding which we know takes place? If you are not with somebody who is trained, that could be very frightening. Do you think it is appropriate that young girls go home and bleed in this way on their own, suffer pain in this way on their own, and then are asked to flush their own abortion down the toilet?

  Liz Davies: We do not send them home in pain or bleeding.

  Q233  Mrs Dorries: They are when they are at home, when the abortion takes place.

  Liz Davies: Yes, but we describe exactly what is going to happen to them. Not all of them suffer the excruciating pain you are talking about. Some women find it a relatively easy process; some find it more difficult. It certainly is not cut and dried. With younger people, we certainly advise them very closely. We would not offer a medical abortion if we thought they were going home on their own without any support.

  Mrs Dorries: As a nurse, I did six months on gynae, and I have never seen a woman have an abortion who was not in pain.

  Chairman: We are asking our witnesses for their opinions here.

  Mrs Dorries: Do you think that talking to somebody and explaining the horrors of the amount of vaginal bleeding and the pain that they are going to go through is done well enough?

  Chairman: With the greatest respect, the witness has answered your question. I am moving on.

  Q234  Dr Harris: I am addressing my remarks to Liz Davis and Dr Argent. We have had a considerable amount of written evidence looking at studies of home administration of prostaglandin, which is already, as I understand it, taken at home by a woman who suffers a natural miscarriage in order to ensure that there is complete emptying of the uterus of the products of conception following a natural miscarriage. We have had considerable evidence from other countries saying that that is both safe, effective and acceptable, and indeed survey evidence from this country which is in our evidence saying that a majority of women would like the option of being able not to have to come all the way back in to take the prostaglandin, as in America where I think over a million have been done in this way perfectly safely. I wonder whether, even if it is not the practice of your particular unit, you would want that option as a provider? I think another provider does do that and has done a number of these and claims to us in evidence that therefore they do earlier abortions very effectively. I would like to ask both of you whether you think that should be an option and whether you think there is some missing evidence out there that suggests that even though it works in other countries, there is something about British women where it would not work.

  Liz Davies: Certainly when British women come to us for medical treatment do question why they have to come back to the clinic a second time for the second medication. Yes, we would certainly advocate that the women should be allowed to take the second part of the medication in the privacy of their own homes without having to travel again.

  Q235  Chairman: Dr Argent, are you aware of the literature that we have received? What is your view?

  Dr Argent: Yes, I agree that there is fairly good scientific evidence that it is reasonably safe to take misoprostol at home and that it is acceptable to women. There does need to be more research on outcomes because the practice of early medical abortion in this country is relatively new. Sometimes it is very difficult to follow up these women and see what happens afterwards. There need to be more robust studies on patient safety.

  Q236  Dr Harris: The Department of Health view is that you cannot take it at home because homes have not been designated as a class of place yet and that the prostaglandin is an abortion in their interpretation of the law. In order to do that research properly as I understand, one would have to change the law because you cannot do the research if it is illegal. Do you think it is reasonable to change the law in order at least to do the research in a carefully controlled way?

  Dr Argent: Yes, personally I would support that.

  Liz Davies: I would, too.

  Kathy French: I think there are two things to say about it. Obviously the safety of the woman is paramount but whatever decision is made, there must be an element of choice for women. There will be, as Nadine has just said, some women who will not want to have that procedure happening at home. They will want possibly the comfort, particularly maybe in the younger age groups, to be in the safety of hospitals. There must be some element of choice there, without doubt.

  Liz Davies: We offer that choice.

  Q237  Chairman: Could I ask the panel briefly on the issue of the psychological impact. Does it vary between a woman having her final abortion at home or having it in a hospital? Is there any research evidence to say there is a different psychological outcome? Is anybody aware of any?

  Liz Davies: Anecdotally from the women who do feed back to us and with whom we engage following their terminations—and we do follow up women—there is no evidence to say that they have a greater psychological impact if they have undergone the process at home than in our clinics. In fact, often they are very grateful for the opportunity to do so. They feel they are able to do this in the privacy of their own homes and not in a clinic with other people around.

  Dr Argent: I understand the private charitable body bpas actually carries out client satisfaction surveys and they have found that there do not seem to be any increased psychological problems, but that is not scientific evidence; that is client satisfaction surveys.

  Q238  Dr Harris: There is a reference here in the bpas evidence to Hamoda et al in the British Journal of Obstetrics and Gynaecology 2005 July edition, which did do a study of the acceptability of home medical abortion to one million UK settings, based, as you say, in four NHS gynaecology units. The record will show that I merely remembered the reference and did not read it out. I would like to ask one more question about counselling. As I understand it, Liz Davies, when you provide abortion services, you have to offer counselling and your counselling services are registered with the Department of Health to assure quality control and there is a chance that they might be inspected unannounced. Is that correct?

  Liz Davies: No, we do not have to register our counselling services. We use qualified counsellors to provide any counselling. Every woman who calls our central booking service to make an appointment is offered the option of counselling. We see counselling and consultations as two discrete and fairly different processes. A woman will choose counselling if she has any ambivalence about whether this is the right course of action for her or whether she just feels she wants to talk to somebody. The majority of women who come to us feel that is totally irrelevant to them; they have made their decision; they have talked to whoever they need. They really just want to have the abortion facilitated as quickly as possible. It is a client-led option rather than an organisational-led condition of having an abortion.

  Q239  Dr Harris: My understanding was, and I may be wrong, that the counselling services that you use if a woman chooses to take it are registered with the Department of Health. Are you aware of that?

  Liz Davies: I am not sure if they are registered with the Department of Health. We always make sure they are qualified counsellors.

  Chairman: Do you think they should be registered so that there is a consistency of counselling service. That is Dr Evans's point.

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