PROFESSOR PATRICIA CASEY, DR ELLIE LEE, PROFESSOR JANE NORMAN, DR CHRIS RICHARDS AND DR SAM ROWLANDS

15 OCTOBER 2007

  Q140  Mrs Dorries: Do you believe that abortion in itself increases the risk of subsequent premature births? If so, do you think that if that is the case again the RCOG guidelines should be updated to inform women that this is the case along with everything else that they are not informed of?

  Dr Richards: I do believe so. I think we have seen in the previous session that the evidence is substantial. There are over 49 articles now, studies, showing an association between prematurity and preterm labour in subsequent pregnancies and a woman having had an induced abortion. It is widely respected in the literature that there is an association. We also have potential causal explanations for why there is an association. The actual process of the induced abortion itself may weaken the cervix. It is conjectural but there are potential explanations for why there should be an association between induced abortion and preterm labour. As Professor Wyatt did say, it is interesting that there is what we call a dose relationship—i.e., the more induced abortions that a woman has experienced, the more likely preterm delivery is going to be in the subsequent pregnancy.

  Q141  Chairman: Could I ask for other views, please, from the panel?

  Professor Norman: Again, I am surprised at what you say about the RCOG guidelines because I have them in front of me and they say that—

  Q142  Mrs Dorries: I have read them also.

  Professor Norman: In your advice to women, they say that you should say there may be an increased risk in preterm delivery in association with abortion.

  Mrs Dorries: Do you not think the RCOG play that down slightly though? I think it is a very important factor for a woman, along with other factors when seeking an abortion, that she is given all the information pertaining to that request. Having been with two teenage girls whilst they requested abortions as part of my own work into a Bill, that has not happened. Nothing that was laid down in the RCOG guidelines was explained to the girls when they went for their terminations. That is why I think maybe they should be beefed up slightly.

  Chairman: That is a different issue to the RCOG guidance itself, is it not?

  Mrs Dorries: I think it needs to be stronger.

  Q143  Chris Mole: Can any of our clinicians with experience suggest whether there is likely to be a difference between a medical abortion and a surgical abortion? If, as Professor Wyatt suggested earlier, there is an increase that is related to infection and cervical damage, is that reduced by the use of chemical induced abortions?

  Dr Richards: I would be very happy to answer that. There was a pertinent study recently in The New England Journal of Medicine which compared medical and surgical abortions over a period of time. Its premise was that surgical abortions did not have a higher risk of any of these complications, including preterm delivery. It said that the rates following medical abortion were similar to those following surgical abortion. If the premise were correct, which I do not believe it is, then it is true that medical abortion would also be safe. If surgical abortion is dangerous and has the complications we have talked about—

  Q144  Dr Harris: Can I have a consensus from the panel? Do we agree or not that all people involved in counselling women for abortion should be registered and regulated in the UK or England with the Department of Health? Does that seem reasonable? Then they can have quality control over what they have said.

  Dr Rowlands: I would support that.

  Q145  Dr Harris: Dr Richards?

  Dr Richards: Can you repeat the question, please?

  Q146  Dr Harris: Do you think that all people providing this information, whether it be doctors or counselling organisations, should be registered and therefore regulated for quality in the content, whatever it is, by in England the Department of Health?

  Dr Richards: Do I believe that a GP who knows the woman best when she approaches for induced abortion should be registered and regulated in the advice that—

  Q147  Dr Harris: They are by the GMC. I am just talking about counselling organisations.

  Dr Richards: This is all part of a general practitioner's work.

  Q148  Dr Harris: I am talking about other people involved because, as you know, there is counselling offered when people come for abortions. I would like to ask the rest of the panel whether they think that is reasonable.

  Professor Norman: I think it is important that women are given appropriate, unbiased advice. Whether that is best achieved by regulation I do not know.

  Dr Lee: I agree with that. Also, I really think that the RCOG and its committee which came up with the guidelines on induced abortion updated in 2004 are not being given a fair enough hearing here. Mrs Dorries is wanting to make the point that what is said in the evidence is not strong enough. The point about the RCOG guidelines which I find very compelling in the process through which they were generated was a very careful process of reviewing the evidence as a whole, taking into account everything that has been published in respected journals and trying to present a balanced account of the sum, rather than emphasising what comes out of particular studies. As a result, it is going to be—

  Q149  Chairman: We are going to have the Royal College in front of us. I would like, particularly from Professor Norman and Dr Richards, an answer to this fundamental question about the health risks to women as a result of abortions and how you assess those health risks.

  Dr Richards: I believe you assess those health risks with individual studies that look at the various different indices that you are concerned about. You have had evidence presented to you about the risk to psychological, psychiatric health. You have had evidence about the risks of subsequent preterm delivery and you have had evidence about breast cancer. I found that collection of studies very powerful.

  Professor Norman: We have discussed psychological sequelae and I do not want to rehearse those arguments again. I would agree there may be an increased of preterm birth associated with induced abortion. We know how we can reduce those risks by treating women earlier. We know that if women have abortions earlier they are less likely to have cervical damage which may lead to preterm birth. If they have their abortions done by people who are expert, again that reduces that risk. I would entirely disagree with you about breast cancer. I think the evidence is compelling that there is no increased risk of breast cancer in association with either induced abortion or miscarriage. There was a very big study done by an Oxford group which was published just at the same time as the RCOG guidelines. They looked at 83,000 women with breast cancer and found no increased risk of breast cancer in women who had had abortions compared to women who had not been pregnant. This view is also endorsed by the American Cancer Society that says the level of evidence about the lack of association between breast cancer and induced abortion is grade one, so that is the best evidence you could possibly get. The American College of Obstetricians and Gynecologists also endorses that.

  Dr Rowlands: I said in my submission that the risk of preterm birth and miscarriage appears to be associated with induced abortion. There are data on that but, as Professor Norman has said, we need to look at things like cervical priming as to how we can reduce these risks. At the moment it seems like medical abortion is very safe but we need more studies on medical abortion because without the instruments it would appear less likely that there would be any mechanical damage to the neck of the womb, but obviously we need more studies on that.

  Q150  Mrs Dorries: Dr Evan Harris asked Professor Casey—and she answered the question—whether or not she was pro-life. Dr Lee, are you pro-choice?

  Dr Lee: Yes.

  Q151  Dr Turner: Out of the women who ask for abortions, do they always fulfil ground C of the Abortion Act, meaning that the continuance of pregnancy would involve risks greater than if the pregnancy was terminated or of injury to the physical or mental health of the pregnant woman? Is that piece of law satisfied by most women who apply for an early abortion?

  Professor Norman: Yes, I would say so.

  Q152  Dr Turner: Does everybody agree with that?

  Dr Richards: I do not agree with it. It is rarely fulfilled.

  Q153  Dr Turner: Can you say why?

  Dr Richards: Because I think the risks of mental health and physical damage to the woman following abortion are substantial and greater than if they continue to delivery. I believe that that ground is rarely fulfilled and is wrongly interpreted by most practitioners in this country.

  Professor Casey: I cannot comment on it in relation to physical illness. I can only comment on it in relation to psychological illness and it certainly is not fulfilled.

  Dr Rowlands: I think it is fulfilled.

  Q154  Dr Turner: We do not have a unanimity of view. Do medical abortions carry a similar risk or greater risk than surgical abortions?

  Dr Richards: We have already mentioned a paper in The New England Journal of Medicine which I think many of us are aware of. I believe it is a Danish study where they looked at the complications of medical and surgical abortion over a period of time. It tells us nothing about the absolute incidence of the complications, such as ectopic pregnancy and preterm delivery, but it does give us some indication about the comparison between the two. Largely speaking, the complications are at the same rate between a medical and a surgical abortion. If the premise is that surgical abortion is safe, you might assume that medical abortion is safe but if you do not—as we have seen evidence for here—then we cannot make that assumption.

  Q155  Dr Turner: Would anyone like to comment on the death rates in the first year following an abortion?

  Dr Richards: It is pertinent to medical abortion that there has been a group of people who have died suddenly following medical abortion. It is a rare infection, clostridium sordelli, and it has probably killed five or seven people in America and Canada. This is very early days to know how frequent that infection is going to be. What was striking was how difficult it was for the doctors looking after these patients to diagnose it. It was very hidden. They did not have fever; they did not have rash and then they suddenly died. It is much too early to assume that medical abortion is a safe means of abortion.

  Q156  Mrs Dorries: Rosie Winterton in reply to a parliamentary question responded that there had been two deaths this year in this country from the same thing.

  Dr Rowlands: On the Clostridium Sordelli, yes, there was one death in Canada in a trial in 2001. There were five deaths in the US between when the mifepristone was launched in 2000 until the present time. During this time, during childbirth, there have been eight cases. The Centers for Disease Control and the Food and Drug Administration had a meeting in May 2006 and unfortunately there is very little information. They agreed to increase surveillance and detection of cases but the point is that death from this condition is rarer than death from anaphylaxis after being given a shot of penicillin. In the US during that time, where those deaths happened, there were 600,000 medical abortions. In Europe there were many hundreds of thousands. The only cases that are recorded are one in Canada, four in California, which is peculiar and no one has been able to explain that, and one in a western state of the USA but nowhere else in the world.

  Dr Richards: The New England Journal review following that article said that it may mean that death from infection from medical abortion is ten times greater than surgical abortion. In other words, they considered that it was a significant observation and may be, but as yet unproven, a substantial risk from medical abortions. We have to be very cautious to say what "safe" means in this content.

  Professor Norman: The RCOG guidelines have come in for some criticism so I think I should say in their defence that, in this particular situation, they do advise that women are screened for particular infections when they have terminations of pregnancy, including Chlamydia, and that antibiotics given prophylactically to women having abortion, both medical and surgical, to minimise the risks of these adverse outcomes.

  Q157  Dr Harris: Can I ask the representative from the Royal College whether you consider medical abortion to be a satisfactorily safe procedure? We know nothing is ever completely safe; walking down the street is not safe.

  Professor Norman: I certainly have not seen anything that makes me think it is not safe. One of the difficulties is we have only been doing medical abortions for, what, ten years, so data is still accumulating. From what we know about the way that medical and surgical abortions are done, it seems to me likely that they will be at least as safe, if not safer than, surgical abortions.

  Chairman: On that note, could I thank Professor Casey for coming from Dublin today, Dr Ellie Lee, Professor Jane Norman, Dr Chris Richards and Dr Sam Rowlands for your patience with the Committee? Thank you very much indeed for your evidence this afternoon.