The Independent Advisory Group on Sexual Health and HIV would like to submit the following response to the Science and Technology Committee enquiry into scientific developments relating to the Abortion Act 1967.

1.  THE SCIENTIFIC AND MEDICAL EVIDENCE RELATING TO THE 24-WEEK UPPER TIME LIMIT ON MOST LEGAL ABORTIONS, INCLUDING:

(a)   developments, both in the UK and internationally since 1990, in medical interventions and examination techniques that may inform definitions of foetal viability; and

  Ultrasound scans early in pregnancy are much more accurate at diagnosing intrauterine pregnancy and confirming gestation and viability. Technological advances in Obstetrics and Neonatal Paediatrics, in ultrasound and cytogenetics for prenatal diagnosis and in-utero surgery for fetal treatments are ongoing. A wider range of foetal abnormalities can be detected, or refuted, and there is increased capacity for treatment of the foetus in utero and baby post delivery. It is argued that abortions should not be performed in pregnancies where the fetus may survive. Data is available on the survival and subsequent disability (or lack of disability) of the very premature eg the Epicure Study1 in which infants born before 26 weeks were followed up till six years of age. However, in births up to 23 weeks gestation, only 7% survived to discharge. Of these 24 children, 63% suffered moderate or severe disability at the age of six. However, the conclusive diagnosis of serious foetal abnormality may still take late into the second trimester or later (for example, awaiting the outcome of amniocentesis for genetic abnormality or the outcome of an anomaly scan), and for those women who feel they cannot continue with such a pregnancy, we believe the need for later abortion procedures continues. A 1987 paper produced jointly by the BMA, Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of General Practitioners (RCGP), Royal College of Midwives (RCM), British Paediatric Association and the Clinical Genetics Society considering the advantages and disadvantages of imposing an 18 week gestational age limit on legal abortion stated that late diagnosis of malformation was inevitable in some pregnancies. It went on to say "it would be inhumane to these mothers, their babies and families to insist on the continuation of a pregnancy when the fetus was known to be seriously abnormal"2

  These technical advances have also brought into question the foetus' ability to experience pain, foetal movements and expressions being attributed to "feeling". Some believe this is dictated by biological development, other that it also requires cognitive faculties, not developed until much later in pregnancy or even in post natal life. The evidence to date is limited but a thorough review of the scientific evidence published in the Journal of the American Medical Association in 2005 concluded that the perception of pain is unlikely below 24 weeks gestation (22 weeks from conception); for example cutaneous withdrawal reflexes and hormonal stress responses present earlier in development not being explicit or sufficient evidence of pain perception and giving evidence for this statement.3

(b)   whether a scientific or medical definition of serious abnormality is required or desirable in respect of abortion allowed beyond 24 weeks;

  We believe it is desirable to define a serious abnormality but accept it may not always achievable ie to absolutely confirm whether there is or is not a serious abnormality, as follows;

(i)  precisely defining the abnormality will not always be possible; diagnostic techniques are not sufficiently advanced to be able to absolutely precisely define the abnormality and therefore consequently predict the "seriousness" of the outcome;

(ii)  definition of the word "serious" as it can be to the fetus who becomes the child (if surviving) intellectually, physically or socially, or to the child's family; a family rejecting of a child unwanted due to disability can result in poor outcomes in both the mother20 and the child and for society (ref Czech study). 22

  An exhaustive list of "serious abnormality" is therefore unachievable for the reasons given. Having a fetus/child with the absolute diagnosis of a known abnormality eg Down's syndrome is still an unknown quantity, from how much one/other/both parents can love the child and give the life every child deserves to how severely affected the fetus/ child will be physically, emotionally and socially.

  We believe you cannot put a scientific definition on "serious abnormality" but can a medical one based on what is agreed between the mother of the pregnancy and the clinicians in charge of her case, taking into account all clinical information available (obstetric and with information from other pertinent specialists eg paediatrician) and the wishes of the mother (ideally parents but ultimately the decision lies with the mother). The Act does not give any guidance about how "serious handicap" should be defined and nor have the courts given any guidance as to how this phrase should be interpreted. The RCOG has listed a number of factors that should be taken into consideration when assessing individual cases,4 as has the BMA.5

  Adequate and unbiased information to enable decision-making is critical. This situation would benefit from having national clinical guidelines/standards set, laying out what information should be available and what staff is involved.

2.  MEDICAL, SCIENTIFIC AND SOCIAL RESEARCH RELEVANT TO THE IMPACT OF SUGGESTED LAW REFORMS TO FIRST TRIMESTER ABORTIONS, SUCH AS:

(a)   the relative risks of early abortion versus pregnancy and delivery;

  there are many references (scientific evidence) in the literature as to the relative physical safety of first trimester abortion as compared to term delivery given both are undertaken in safe conditions.6 A paper this year in the New England Journal of Medicine7 reported lack of evidence for early medical abortions increasing the risk of spontaneous abortion, ectopic pregnancy, preterm birth, or low birth weight in subsequent pregnancy compared to surgical abortions, given previous research had shown the safety of surgical abortion. There is the defined condition "post natal depression" accepted by psychiatrists but, psychiatrists have yet to define a "post abortion syndrome". The US House of Representatives Committee on Government Operations (1989) under Surgeon General Koop failed to find evidence for this syndrome.8 No overall increase in psychiatric morbidity was found in an English study.9 Research proposes that severe negative reactions are rare and can best be understood in the framework of coping with a normal life stress. 10

(b)   the role played by the requirement for two doctors' signatures; and

  two signatures were put into the 1967 Abortion Act to show the seriousness of the decision to terminate. Clinical standards are maintained through informed consent and the adherence to Good Practice Guidelines such as those of the Royal College of Obstetricians and Gynaecologists.6 We would argue that if the issue is the maintenance of standards, then that is addressed by commissionable and performance managed national clinical guidelines. There is an argument to wish the involvement of two appropriately trained and experienced clinicians in more complex cases eg fetal abnormality, the very young and the vulnerable to evidence the case has been given the clinical involvement it merits which we support. If this were to be the case, good practice may suggest there are professionals as appropriate as doctors to fulfil this role. However, this is a separate issue from signing the HSA1 which is not just one but two persons having the right to have ultimate say what is or is not in the interest of another consenting person (who by definition has been judged competent to weigh all pros and cons and reach a conclusion herself ie is fit to give informed consent). We know of no scientific or medical evidence supporting the need for two signatures and question the right of any person to veto the rights of a competent other to make decisions about their own health and wellbeing.

  The current use of the Abortion Act by the population and the profession (98% are done under clause C or D, though this is all gestations) and the ability to sign the HSA1 without seeing or examining the woman is on its own evidence that the two signatures are anachronistic. Overall, polls show women support the right to abortion. 11 The GMC Guidance that if a doctor cannot support a request for abortion, alternative provision must be offered is also evidence for the belief in a woman's autonomy to seek help. The refusal to sign HSA1 does not prevent a woman from going to another provider for a signature.

  We know of no research in this area ie the role played by the Doctor re HSA1 but there are surveys re women's attitudes, opinions and wants.

  one signature is unlikely to cause delay as the HSA1 is usually signed by the doctor doing the medical aspects of the pre-assessment: the need for two signatures has the potential to cause delay. However, it is difficult to tease out how much delay is related to signatures. Delay increases clinical risk and may prevent access to early medical abortion (as opposed to surgical). Women commonly have to find a doctor who will refer; few NHS provided services have self referral. The referring doctor may or may not provide a signature. Nurse -led services by definition cannot provide signed HSA1s with referral. Time can be spent while the signature is sought (good services eg Liverpool, Hull, ensure signatures as part of the service but this does not have to be the case). Also, some services send women back to their GPs for the second signature when the abortion has been granted by the provider service; the woman is then put in the difficult position of finding a signatory if her GP will not sign. Finding two signatures have the potential for causing further stress/distress to the woman who is already distressed. She goes to someone to ask for referral and risks being made to feel bad about herself/turned away and told to go elsewhere, a cause of short-term distress. 12 It could be argued this is about service provider attitude and nothing to do with HSA1s but right now most women access abortions through their GPs or Family Planning clinics (women will guess access is available via the GP but many are not aware of access through their FP service) 13 and do not know the GP/FPs' clinicians stance on the topic14 (this alone is stressful). 15 It therefore does not make sense, in the absence of any evidence otherwise, for the system per se to be a source of distress and possible delay unless it is shown there is the need for two signatures.

(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 the patient's home; and

  Nurses and midwives in the UK already take part in many aspects of abortion care; many early medical abortion services are increasingly nurse led and nurses and midwives undertake patient care in late medical abortion. What nurses are allowed to do vary from State to State in the USA. As of January 2004, trained advanced practice clinicians were providing medical, and in some cases, early surgical abortion in 14 states. 16 Nurses and midwives run services in South Africa with excellent safety profiles. 17 Nurses already undertake highly skilled surgical services in gynaecology and other surgical specialties. Given the evidence, we consider enabling trained, competent nurses/midwives to carry out early surgical procedures should be both safe and practical.

  The evidence is that it is perfectly safe for the second stage of early medical abortion to be carried out at home within the structure of properly organised services. 18

3.  EVIDENCE OF LONG-TERM OR ACUTE ADVERSE HEALTH OUTCOMES FROM ABORTION OR FROM THE RESTRICTION OF ACCESS TO ABORTION

  There are many publications on the physical risks of abortion in the short and long term (infection/ haemorrhage, injury in the short term, infertility secondary to infection and rarely injury in the long term; debate is ongoing on increased risk of miscarriage and pre-term delivery. There is no evidence for an increased risk of breast cancer, placenta praevia or ectopic pregnancy.) These are well quantified and presented, along with actions to minimise risk, in the RCOG Guidelines on Abortion6 and subsequent research.

  There is much published on the adverse long-term psychological outcomes but many of he studies are of poor scientific quality eg the samples are not representative of the population.

  The American Psychological Association and American Psychiatric Association do not recognise "Post Abortion Syndrome" through lack of evidence.

  Adler has given evidence to US House of Representatives (March 16, 1989) 19 in which she summarises studies by saying the predominant feeling following abortion is relief and happiness, the incidence of severe negative reaction is low and factors are known which put women at greater risk (eg planned pregnancy, second trimester procedures, partly due to the nature of women accessing later abortions, poor support) and she published on the emotional responses following abortion, positive and negative. 12 The Koop Report could find no conclusive evidence for mental health problem.8

  There is not a lot of clinical study on restriction to access. A paper from the UK on a large cohort study (13,000 women)by GPs reporting psychiatric morbidity showed psychiatric disorder no higher after abortion than pregnancy Pre-existing psychiatric illness was a risk for both groups. The abortion group showed more deliberate self harm but greater in those refused an abortion, indicating confounding variables such as adverse social factors.9 A Swedish survey showed significant emotional disturbance in 24% of women at follow-up with one third of these mothers judged to be providing a poor environment for their children. 20 The evidence is children of unwanted pregnancies forced to continue do less well than controls ie wanted children. A rigorously control matched study published in 1980 showed teenagers whose mothers had been denied abortion had poorer school performance, more adverse psychological symptoms and more likelihood of registration with social services. 21 A long term follow up study from Prague22 (Born Unwanted, 35 years later) with long-term follow up showed the adverse effect on the children of women denied abortion compared to controls; poorer school performance and more behavioural problems as children and more criminality, job dissatisfaction and poorer socialising as young adults .

REFERENCES

1  Marlow N et al Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. 2005; 352 (1):9-19.

2  Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of General Practitioners, British Medical Association, British Paediatric Association, Clinical Genetics Society. Report on the advantages and disadvantages of imposing an 18 week gestational age limit on legal abortion. London: Royal College of Obstetricians and Gynaecologists. 27 November 1987: para 3.1.

3  Lee SJ et al. Foetal pain: a systematic multidisciplinary review of the evidence. JAMA 2005; 294: 947-54 and correspondence JAMA 2006;2 95:159-161.

4  Royal College of Obstetricians and Gynaecologists. Termination of pregnancy for fetal abnormality in England, Wales and Scotland. London. RCOG Press. 1996.

5  British Medical Association Ethics Department. Medical ethics today. Th e BMA's handbook of Ethics and Law. 2nd ed London: BMJ Books. 2004:242-3.

6  Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion. National Evidence-based Clinical Guidelines. 2004. www.rcog.org.uk

7  Virk J et al. Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med 2007;357: 648-53.

8  Medical and Psychological Impact of Abortion. Hearing before the Human Resources and Intergovernmental Relations Subcommittee of the Committee on Government Operations House of Representatives. One Hundred First Congress.

9  Gilchrist AC et al. Termination of pregnancy and psychiatric morbidity. B J Psych 1995; 167: 243-8.

10  Adler NE et al. Psychological responses after abortion. Science,1990 ; 248, 41-44.

11  Women's perceptions of abortion law and practice in Britain, 2002. Independent survey by BMRB Social Research for Marie Stopes. This gave little support for doctors having anything but a consultative role in decisions relating to fertility regulation.

12  Adler NE (1975) emotional responses of women following therapeutic abortion. Am J Orthopsychiatry 45(3) 446-454.

13  A Quest for Abortion; Research from Voice for Choice presented at the All-Party Parliamentary Pro-Choice Group, December 1999.

14  Obstruction by clinicians but not to do with 2 signatures specifically; Late; a study of women undergoing abortion between 19 and 24 weeks. MSI 2004.

15  Case studies from General Practitioners Attitudes to Abortion. A report by MSI. June 1999.

16  Joffe C, Yanow S. Advanced practice clinicians as abortion providers: current developments in the United States. Reprod. Health Matters. 2004;12 (24 suppl):198-206.

17  Warriner IK et al rates of complications in 1st trimester manual vacuum aspiration done by doctors and midlevel providers in South Africa and Vietnam; a randomised controlled equivalence trial. Lancet 2006;368:1965-72.

18  Fiala C et al Acceptability of home use of misoprostol in medical abortion. Contraception 2004;70: 387-92.

19  Statement of Nancy E Adler. For: Medical and Psychological Impact of Abortion. Hearing before he Human Resources and Intergovernmental Relations Subcommittee of the Committee On Government Operations House Of Representatives. One Hundred First Congress. 1st session. March 16, 1989.

20  Hook K. Refused abortion. Acta Psychiatrica et Neurologica Scandinavica 1963;39. Suppl 168:3-156.

21  Blomberg S Influence of maternal distress during pregnancy on postnatal development. Acta Psychiatrica et Neurologica Scandinavica 1980;62: 405-17.

22   David HP. Born Unwanted, 35 years later: the Prague Study. Reprod. Health Matters. 2006;14: 181-90.

September 2007