Examination of Witnesses (Questions 220-239)
DR VINCENT
ARGENT, DR
TONY CALLAND,
LIZ DAVIES
AND KATHY
FRENCH
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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