1.0  EXECUTIVE SUMMARY

  1.1.0  The Royal College of Nursing (RCN) welcomes the opportunity to make a submission to the Committee's inquiry into the scientific developments relating to the Abortion Act 1967. The RCN's response to this inquiry concerns abortion services from a clinical perspective and does not specifically examine the ethical issues surrounding abortion.

  1.1.1  The RCN has hitherto supported the availability of abortion under the current legislation. The Act was originally passed to safeguard the lives of women with the desire to end illegal and dangerous abortion and set out a range of conditions and safeguards for women which included specifying where abortions could take place, and under what circumstances. The Act does not relate to Northern Ireland and therefore this response does not refer to the current arrangements in place in NI.

1.2  RECOMMENDATIONS FROM THE RCN

—  The RCN continues to support the current law that enables abortion up to 24 weeks gestation.

—  The RCN believes that the requirement for two doctors to agree that a women can have an abortion should be removed.

—  The RCN recommends a change or clarification in legislation to allow nurses and midwives to be allowed to perform early surgical abortions and to be able to prescribe Mifespristone for early medical abortions as part of a clinical team.

—  The RCN recommends a change in the British National Formulary (BNF) to allow independent nurse prescribers to prescribe the abortion pill (Mifepristone).

—  The RCN would like to see clear standards of care for all women seeking abortions to minimise the differences in care in different locations.

—  The RCN recommends accredited appropriate training for nurses and midwives who wish to work in a setting where they are providing early abortion services.

—  The RCN believes that women should have access to long acting reversible contraceptive (LARC) methods as per the NICE guideline 2005.

—  The RCN would like to see that in every provider unit, all women seeking abortion have access to screening for STIs and treatment, if indicated, before their procedure in order to reduce the incidence of pelvic inflammatory disease (PID) post procedure.

—  Reducing the stigma around abortion is vitally important. The RCN believes that the above recommendations will contribute towards achieving this aim.

2.0  INTRODUCTION

  2.1  The RCN represents over 390,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets in the UK. This makes the RCN the largest professional union of nursing staff in the world. The College promotes patient and nursing interests on a wide range of issues by working closely with government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

  2.1.3  The RCN recognises that not of all its members will feel comfortable with working in a service where they might be or are required participate in abortion provision. The RCN makes available guidance to its members on s.4 of the Abortion Act (1967) which states that individuals are under no obligation to "participate in any treatment authorised [by the Act] to which [they have] a conscientious objection." As an organisation we are here to support our members in providing the very highest standards of care possible for their patients and clients. We acknowledge and respect those nurses who have a conscientious objection to providing abortion care but are committed to providing support to those nurses who work in abortion care to provide safe, effective and quality care.

2.2.0  Q 1  Scientific and medical evidence relating to the 24-week upper time limit on most legal abortions, including:

2.2.1  A)   Developments, both in the UK and internationally since 1990, in medical interventions and examination techniques that may inform definitions of foetal viability

  2.2.2  One of the key technological developments since 1990 has been the ability to view the developing foetus in increasing detail via 3D and 4D ultrasound scanning. These images provide a three-dimensional view of the foetus and have been used to demonstrate the close resemblance of the foetus to a neonate, in an attempt to strengthen the claims of those opposed to abortion that killing a foetus is analogous to killing a neonate. The RCN's view is that 3D and 4D imaging only serves to reveal what is already known, but with greater clarity.

  2.2.3  Improvements in neonatal care have led to unrealistic expectations about the medical ability to sustain life at early gestation. Survival rates for babies born very early remain low; at 21 weeks gestation zero percent survive; at 22 weeks 10% survive and just 26% survive at 24 weeks (Costeloe et al 2000). Survival in itself does not, of course, determine quality of life, which can be considerably affected by premature birth.

  2.2.4  Currently 90% of abortions are carried out before 13 weeks and 98% are carried out under 20 weeks. Only a very small proportion of abortions, just two percent, are carried out after 20 weeks. There are a number of reasons why women present at this late stage. They include young women in denial of their pregnancy, older women who have not had a period for a long time or are in the early stages of menopause unaware that they could be pregnant, women using the Depo Provera contraception injection which causes amenorrhea, or women for whom there has been a difficult change in personal circumstances. (Pro-choice forum. Late abortion: a review of the evidence. 2004)

  2.2.5  There are no developments in technology to suggest that viability has altered, yet being able to perform an abortion up to twenty-four weeks is of enormous importance to this very small but important group of women. The RCN continues to support the current legislation that enables abortion up to 24 weeks.

2.3.0  B)   Whether a scientific or medical definition of serious abnormality is required or desirable in respect of abortion allowed beyond 24 weeks

  2.3.1  In 2006 only 2000 (one per cent) of abortions were carried out under section E of the Abortion Act 1967. (Department of Health Statistical Bulletin. Abortion Statistics: England and Wales 2006). The social implications that determine a definition of "abnormality" and the inherently subjective components of such a definition must be taken into consideration and the RCN believes that they should, in many instances, outweigh a scientific or medical definition when making decisions regarding abortion.

3.1.0  Q2  Medical, scientific and social research relevant to the impact of suggested law reforms to first trimester abortions, such as:

3.1.1  A)   The relative risks of early abortion versus pregnancy and delivery

  3.1.2  The National Strategy for Sexual Health and HIV (Department of Health 2001) set a target that women seeking abortion should have access to this service within three weeks and this was further recommended by the Medfash Standards for Sexual Health in 2005. Evidence suggests that abortion is safe but complications and risk increase as gestation progresses, therefore the earlier in pregnancy an abortion takes place the safer it is for the woman. However, regardless of gestation; abortion is safer than pregnancy and delivery (RCOG. The care of women requesting induced abortion. 2004; 23). This is reflected in the NHS QIS Scottish Standards for TOP (June 2007).

  3.1.3  The reported complication rates for abortion are about two in every 1000 abortions (ibid.). Conversely, only 47% of deliveries are classed as "normal" and complications occurring in the ante, intra and post partum period are numerous. (NHS Information Centre 2007. Maternity Statistics England 2005-06) Moreover it could be argued that the relative risk of abortion has decreased since the introduction of medical abortion. (First Trimester Abortion: a briefing paper by the BMA's medical ethics committee BMA, 2007)

3.2.0  B)   The role played by the requirement for two doctors' signatures

  3.2.1  Seeking an abortion requires that the woman's consent is both fully informed and autonomously given, however, under the existing law, abortion remains a crime under s.58 and s.59 Offences Against the Persons Act 1861 and the Infant Life Preservation Act 1929, for which the Abortion Act 1067 provides a set of defences. The law hands over responsibility to doctors to make the judgement about whether any of these defences apply. (Paton v Trustees of BPAS p992; C v S [1987] 1 All ER 1230).

  3.2.2  In R v Smith [1973] Lord Justice Scarman noted: "The Act, though it renders lawful abortions that before its enactment would have been unlawful, does not depart from the basic principle ... that the legality of an abortion depends on the opinion of the doctor."

  3.2.3  The requirement for the opinion of the doctor is a risk assessment—that the balance of the risk between termination and continuation of the pregnancy—has been contemplated by a doctor. Montgomery argues that "this is reinforced by the fact that the Abortion Act makes a legality of a termination depend, not on whether the grounds are actually made out, but whether two doctors believe that they are in good faith" (Montgomery J. p.383, Health Care Law 2nd edition, Oxford).

  3.2.4  The current requirement of two medical practitioners' signatures is not only out-dated but can lead to delays in the referral process for women and therefore increases the risk as gestation progresses.

  3.2.5  There is no other medical or surgical procedure which requires the consent of a medical practitioner or the signature of two doctors before it is carried out. It is demonstrable that the requirement is simply a paper exercise. The RCN believes that a competent woman seeking an abortion is able to give informed consent to any procedures carried out (excepting medical emergencies that may arise where this is not possible). Her consent would be based upon an explanation and understanding of the available methods of abortion including complication rates and follow-up care.

  3.2.6  The RCN further believes that the request for abortion should be made by the woman and not by two doctors on her behalf. Therefore the RCN believes that the requirement for two doctors to sign consent for an abortion should be removed from the legislation.

3.3.0  C)   The practicalities and safety of allowing nurses or midwives to carry out abortions or of allowing the second stage of early medical abortions to be carried out at a patient's home

  3.3.1  Nurses and midwives are currently providing high quality, patient centred nursing care within abortion services offering physical, emotional and social care and support to women and their families. Nurses working within these services wish to improve access and ensure women receive a safe, effective and seamless service with the least delay.

3.4.1  Surgical abortion

  When the Abortion Act was passed in October 1967 it was not common practice for nurses and midwives to perform surgical procedures; however nurses and midwives have expanded on their practice and now perform a range of complex procedures including colposcopies and hysterosopies, and fitting intrauterine devices (IUDs) and sub-dermal implants.

  3.4.2  There is a lack of clarity in the legislation. The Abortion Act states that a legally induced abortion must be performed by a registered medical practitioner. Previous cases (RCN v DHSS 1981) have examined what "registered medical practitioner" means in relation to medical abortion. However, the interpretation of "registered medical practioner" to include nurses and midwives for the purposes of performing surgical abortions has been rejected by the Department of Health.

  3.4.3  The RCN believes that registered nurses and midwives with appropriate training and who are appropriately accredited in abortion care should be allowed to perform early surgical abortions. The RCN believes that this should could be addressed either by expanding the definition of "registered medical practioner" in the legislation or by allowing a broader interpretation under the existing wording.

  3.4.4  In these circumstances, the RCN believes that nurses and midwives should be part of a team in providing care. They should have the clinical support of a registered medical practitioner who is an expert in the field and be part of the whole team providing abortion. (First Trimester Abortion: a briefing paper by the BMA's medical ethics committee BMA, 2007)

3.5.0  Early medical abortion

  3.5.1  In many services nurses and midwives already provide the total care package to women having early medical abortion with the exception of being able to prescribe the medication needed. Mifespristone is listed in the BNF for Nurse Independent Prescribing (NIP) but cannot be prescribed by nurses in abortion cases. Allowing nurses and midwives to extend their role would prevent women in some parts of the UK being delayed in seeking an early abortion.

3.6.0  Early medical abortion second stage at home

  3.6.1  Whilst it is becoming common practice to carry out abortions in the home in the USA, this practice has not been evaluated in the UK. Without evaluation it is not possible to recommend this practice at this stage.

  3.6.2  A survey amongst women in 2006 which was sponsored by the fpa found that whilst 71% of those questioned thought that all procedures that took place in the hospital could be provided in the home, sixty-four per cent indicated that they would prefer to undergo an abortion in a hospital (Hamoda, 2005).

4.1.0  Q 3)   Evidence of long-term or acute adverse health outcomes from abortion or from the restriction of access to abortion

  4.1.1  It has been reported that the incidence of psychological sequelae following abortion is rare and as such there is no scientific evidence for the often used phrase "post-abortion syndrome". (Schmeige S, Russo N. Depression and unwanted first pregnancy: longitudinal cohort study. BMJ 28.20.2005)

  4.1.2  The emotional distress following an abortion is related to the degree of emotional distress before the abortion and can be linked to issues that may have contributed to the request for abortion. (National Abortion Federation. www.pro-choice.org/about_abortion/myths/post_abortion_syndrome)

  4.1.3  It is very difficult to calculate adverse health outcomes from abortion or from the restriction of access to an abortion. There is currently no written evidence on this issue. One of the reasons for this is that, as with other aspects of sexual reproductive health, service users are unlikely to complain if they receive poor standard of care. It is also difficult to pinpoint what the cause of any adverse health outcomes may have been, as the difficult personal, social and psychological circumstances that let to the abortion rather than abortion itself may be the cause of mental health problems.

  4.1.4  Some women report difficulties in their journey through the abortion process. There are a number of reasons for this. The current need for two signatures can cause delay unintentionally. It has also been reported anecdotally that some GPs who are personally not in favour of abortion may delay the referral, for example, by making the women have a pregnancy test first and then waiting several weeks to reveal the result. Other women may experience delays due to the provision of local services or lack of funds. Such delay may have a negative impact on health outcomes. The outcome for women in these circumstances is often traumatic and adds to feelings of guilt that some may experience.

August 2007