Examination of Witnesses (Questions 320-339)
RT HON
DAWN PRIMAROLO
MP, DR FIONA
ADSHEAD AND
PAULA COHEN
24 OCTOBER 2007
Q320 Chairman: I think the Committee
members, who are of different persuasions, would share the view
that if abortion is taking place it should be taken earlier rather
than later. But would you consider, for instance, the advice from
the Royal College of Obstetricians and Gynaecologists and the
BMA about first trimester abortions and of getting rid of the
two doctors' signatures which seem to be a barrier to early abortion?
That would require legislation.
Dawn Primarolo: It would require
legislation.
Q321 Chairman: And that would be
the Government following its policy.
Dawn Primarolo: And if the House
decides—because it has always been agreed that these matters
are decided by the House. But the information under the current
arrangements is that 89% are before 13 weeks—and we continue
to try to improve the service—and 68% are ten weeks or less.
That seems to be the correct way to go. I have confined myself,
very clearly, Mr Willis, in making sure that, as the law currently
stands, the Health Service is pursuing policy as expressed by
this House in debate, and that includes, wherever possible, ensuring
that abortions are taken as early as possible.
Q322 Chairman: On the point that
Nadine is making in terms of policy, in terms of getting it from
late to early, if you felt that a change in the law would facilitate
that, you still would not do that unless it came through the private
Member route.
Dawn Primarolo: No, it would have
to be a matter for the House. It would have to be a matter for
the House because views are so strongly held. I speculate here,
but the Department would be required to come to the House if there
was a problem; but, given the percentage, the assessment is that
there is not a problem and, therefore, although there are increasing
views expressed with regard to two doctors or one doctor, that
would still have to be a matter for the House and not for Government.
That is the position the Government has held for some time.
Chairman: One of the key areas we are
dealing with at the moment is this question of viability. I want
to bring Dr Turner in.
Q323 Dr Turner: The Infant Life (Preservation)
Act 1929 still makes it an offence to intentionally kill a foetus
capable of being born alive. The Act stipulates that if the foetus
is 28 weeks of gestation or older it is capable of being born
alive. What does "capable of being born alive" mean
to you and to the Department? Does this Act possibly confuse "vitality"
with "viability"?
Dawn Primarolo: We take the clear
consensus—and I will come back to this time and again in
terms of the evidence presented here this morning—in the
way that the Department proceeds. In particular, we would be looking
at the survival rates to discharge as a measure of viability with
regard to the 1967 Act. I can say to you that all the research
and information we have and the consensus view is that survival
to discharge is the point of viability—which helps reinforce
that concept—and at 21 weeks it is 0%; at 22 weeks it is
1% and then it increases quite markedly at 23 weeks to 11%. In
this very complex area with regards to time and viability, we
are following the medical consensus, and that medical consensus
still indicates that, whilst improvements have been made in care,
at the moment that concept of viability cannot continually be
pushed back in weeks: it is a matter of development and therefore
survival rates. That is where we draw our views on that matter.
Q324 Dr Turner: Do you currently
see whether there is a legal age of viability? In answering that
question, if you could give your view on the latest data concerning
the viability of those highly pre-term and pre-term babies it
would be helpful, because the two things go together.
Dawn Primarolo: I will ask Paula
to answer in a moment on the question of the legal status. The
Act clearly makes requirements with regard to time limits. The
results of studies commissioned by the Department which I have
just quoted for 1995, and I understand that the latest results
will show similar—
Q325 Dr Turner: We have seen a private
view of that data.
Dawn Primarolo: Certainly the
advice from the British Association of Perinatal Medicine—which
I think they have also stated in their evidence to you—is
that a lowering of the legal definition of viability, as we operate
it, to discharge, would imply that the viability of survivals
have improved, and they have not on the consensus of evidence
we have. Some disagree with that, of course, but, in drawing on
all the evidence, we draw to the point where the consensus—
Q326 Chairman: Whose evidence do
you rely on?
Dawn Primarolo: We are relying
on the BMA; the RCOG; the RCN; the EPICure studies. We are relying
on the British Association of Perinatal Medicine; the Department's
library tracts; research in this area. We make sure that, if relevant,
it is drawn absolutely to the attention of the officials who will
be concerned with this area. There are regular meetings and discussions
between the experts. We also would track right down to newspaper
articles and reports. We are looking at international research
and consensus. So we are drawing as widely as possible to have
a clear position—or as best we can have a clear position—on
what are very difficult issues. Hence my point that I can say
to the Committee what the Department knows and how it deals with
these areas in the operation of the Act.
Q327 Dr Turner: It would be fair
to say, then, that as far as the Department is concerned there
has been no significant change in the perceived link between age
and viability of 24 weeks and the upper abortion limit under present
legislation of 24 weeks. But there is one important point that
would also affect the 24-week viability data, and that is what
"24 weeks" actually means in practice. It is my understanding
that when births are reported, a delivery in the 24th week of
gestation could be 24 weeks and no days or up to 24 weeks and
six days. That can make quite a considerable difference. Do you
feel that there is any need to be more precise about the meaning
of the 24th week, especially given the fact that measuring gestational
age is not a totally precise science?
Dawn Primarolo: Anything that
is "24 weeks plus" is over.
Q328 Chairman: By one day?
Dawn Primarolo: Yes. That is my
understanding.
Q329 Chairman: Could we ask the lawyer
if that is her view, please?
Dawn Primarolo: Yes, we can. But
we are also held here with the issues with regard to the medical
judgment: the doctor is quite clearly acting within the guidelines
that are issued through the medical profession as to the proper
interpretation and, therefore, how the doctor is expected to make
that judgment with regard to the time it is. I am happy to ask
the lawyer whether I have that wrong.
Ms Cohen: The 24th week is 23
weeks plus six; so 24 weeks plus one is over the legal time limit[1].
As to when to start the calculation, commentators have looked
at that and outlined the various different dates, none of which
have, as it were, reached a conclusive conclusion on when to interpret
the period from.
Q330 Dr Turner: This is an important
point. Could I ask Dr Adshead what medical practice in reporting
deliveries is. In other words, when you receive your data, what
does 24 weeks mean in practice?
Dr Adshead: Twenty-four weeks
is, as interpreted by the Act—the Minister is correct—that
one day and 24 weeks is not 24 weeks. The point the Minister makes
around the issue of the doctor's view is absolutely critical,
because, as we know on a case-by-case basis, it is absolutely
critical that two doctors both advise the woman, look at the context
for her and her health and the broader issues for the family as
well, and, whilst gestational age in terms of being able to do
that from a clinical point of view, in terms of determining data,
has improved vastly since the amendment was made in 1990, there
can still be some variation. That is why we think it is so important
that also the clinical view is taken into account as part of this.
Q331 Dr Turner: What is your current
estimation of gestational age?
Dr Adshead: We do not collect
data on that. We rely on the clinicians recording—
Q332 Dr Turner: You must have a view.
Dr Adshead: I do not have a specific
view on that. I do not know what that would be.
Q333 Dr Turner: We have been given
estimates of, say, plus or minus a week. Does that sound reasonable
to you?
Dr Adshead: That sounds within
the time limits that you might expect but I do not know the precise
answer to your question.
Chairman: Could I bring in Nadine, please.
Q334 Mrs Dorries: You quote the EPICure
study, which as you know, I am sure, averages out the statistics
across the UK of all the hospitals. Are you aware of some practices
taking place in some of your own hospitals, such as Hope in Salford
and University College Hospital London, which report survival
rates in neonates at 23 weeks as 42% and at 24 weeks as 66%? You
also quoted you took information. Are you aware of the Hux(?)
report from Spain: at 23 weeks it is 66% and at 24 weeks it is
82%? If you look at individual units where there are good neonatologists
and good neonatal units, the survival rate is much higher. Therefore,
do you still feel the rate of viability of 24 weeks is right,
given that you are depending on information which simply averages
out, across the UK, bad and good practice?
Dawn Primarolo: Yes. I have tried
to make it clear—and I will make it clear again—that
I am not saying that all the evidence is brought together here.
We are looking at the consensus, quite clearly, on large studies
and the figures that I think you said you already had, Mr Willis,
were with regard to survival rates at 21 weeks, 22 weeks and 23
weeks, and certainly the evidence with regard to the British Association
of Perinatal Medicine is pointing quite clearly to the point that
viability, whatever the vast improvements—and there are
significant improvements—cannot constantly be pushed back
in terms of the date.
Mrs Dorries: I am sorry, that is not
right. That is not correct.
Chairman: Would you ask a question, please.
Q335 Mrs Dorries: I am sorry. That
is not correct. EPICure has not shown that. EPICure has simply
taken the forms which have been returned to it from hospitals
across the UK stating viability figures. It has not taken into
account the performance of individual hospitals across the UK
where the survival rate of infants is much higher than EPICure
suggests. Would you not accept that in your own hospitals viability
rates are quite high where there are good neonatology units?
Dawn Primarolo: I am putting two
sets of evidence that compliment the conclusion about viability
and development which is regardless of significant improvements
in particular hospitals. It is to do with the viability, for instance,
of whether the lungs are developed or not. I am trying to be very
careful with the Committee because I understand that, as in Parliament,
there are very different views. To play this with a straight bat
to the Committee, the consensus of the scientific information
is still clear and the medical advice is still clear with regard
to survival rates under 24 weeks. I would absolutely acknowledge
that there are improvements in care but the advice is still the
same to me in terms of the survival rate below a certain date.
Q336 Chairman: We could argue this,
Minister, and you have made your position clear, but, in policy
terms, the question is whether in fact the policy says we look
at the average across all units, in all types of settings—which
currently is 24 weeks. That is the basis and that also gives the
protection in law from the 1929 Act. The point which some members
of the Committee are making is that the policy should reflect
the very best that is achievable and, therefore, that rate should
come down. Would you concede that that is a legitimate point of
view and one that the Government should consider?
Dawn Primarolo: It is not for
me to say it is not a legitimate point of view, it is not—
Q337 Chairman: I am sorry, it is
an alternative point of view, and should the Government consider
it.
Dawn Primarolo: It is an alternative
point of view, but it is not the view the Government holds. Of
course, in considering any of these matters, the Department of
Health, in its advice, would need to look very carefully at all
of these issues to see whether or not ministers were receiving
the best information that was available to reach a consensus.
The advice to me, apparently, is that that is what the Department
does. I absolutely hear the point that is being made. I am not
disputing whether it is an alternative way to consider this, I
am explaining how the Department proceeds in gathering all the
information in what is a difficult area to come to a conclusion
on the consensus of medical opinion. We do not rely on just one
source of information, clearly we have to balance a whole range
of sources.
Q338 Dr Turner: Is it fair to say
that the Department's view is that in the light of all the evidence
you are currently content with the present 24-week limit?
Dawn Primarolo: The Department's
view is yes. At the moment that is what Parliament have decided
and that is where we are. You are asking me for information of
whether that seems a sensible position to hold. I am saying yes,
because that is the information that comes to me. I want to be
very careful here, though, Dr Turner: it is for the House to decide
on that. I am explaining how the current limits operate and why
we think they are the right limits, bearing in mind the information
we have.
Q339 Dr Turner: I am simply seeking
the Government's view on that.
Dawn Primarolo: The Government
does not have a view. I am giving you the Department's information.
It is a matter of conscience for the House.
1 Note from the Witness: The Department has
submitted a memorandum to correct this sentence. Back
| 
