Special Report – Abortion Services by The Magazine Production Company

SPECIAL REPORT

Abortion Services

Is Abortion and Contraception Policy Meeting Womenâ&#x20AC;&#x2122;s Needs? Abortion, the Law and the GP The Interests of the Foetus Reasons for Decisions Abortion is a People Issue

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Is Abortion and Contraception Policy Meeting Women’s Needs?

bpas

Two Decades of Progress Barriers Remain There Are Still Those Who Argue Against Abortion Counselling The ‘Abortion Pill’ – Still Not For Home Use in Britain Countering Protestors Obstacles Remain in Obtaining Advice Bpas is Awarded ‘Adult Sexual Health Service/Project of the Year’

Abortion, the Law and the GP

John Hancock

The Abortion Act Today GPs on the Front Line Requirements and Obligations Plenty of Guidance Available

The Interests of the Foetus

Peter Dunwell, Medical Correspondent

Term into Pregnancy Disabilities and Abnormalities Other Conditions Lifestyle

Reasons for Decisions

John Hancock

Rights of the Woman Practical Considerations Social Considerations Boy or Girl Alternatives Real Reasons

Abortion is a People Issue

Camilla Slade, Staff Writer

Not a Political Issue Welfare Physical Risks Mental Risks Society Conception

References

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SPECIAL REPORT: ABORTION SERVICES

Foreword T

he termination of a pregnancy, abortion, is

the 1861 Offences Against the Persons Act still

a subject that engenders strong views on

applies. Within this legal framework, there are both

both sides of the argument; views that are often

explicit and implicit responsibilities for clinicians

expressed in very heated or even extreme actions.

and especially for GP’s. But, while the process of

It is also one of those issues where both sides of

abortion has to be confined within the limits of the

the argument can marshal research results and

law, the issue of abortion is one that is intensely

experience to support their case. So it is no easy

personal and should always be about the welfare

matter on which a GP has to advise.

of those involved, i.e. which course of action will

This Special Report opens with a piece from The British Pregnancy Advisory Service (‘bpas’),

bring about the best outcome for them. However, saying it is not to suggest that it is easy.

Britain’s largest single abortion provider, caring

Perhaps because her health is immediately on the

for 55,000 women with unintentional pregnancies

line, the mother’s welfare is a primary concern for

each year. The piece traces the progress that has

anybody involved with counselling on or performing

been made over the last two decades in abortion

abortions. As importantly, there is the welfare of the

provision and the innovations introduced, from

foetus both as an unborn child and considering

nurse-led provision and localised early treatment

what quality-of-life it might achieve if proceeding

services to the provision of choice of treatment

to full term and birth.

method and the ability for women to self-refer into

In the articles that make up this paper we

the service. Against this progress, it examines the

endeavour to address the key issues that GPs will

continuing barriers to improvement in abortion care,

need to take into account when advising patients

and the politically-motivated attempts to undermine

on abortion matters. We look at how the law is

the credibility of abortion clinics and to trivialise

constructed, what might impact on the welfare of

women’s reasons for needing abortion. A highlight

the mother and of the foetus and what issues the

of the work of bps was its recent Christmas initiative

GP might need to take into account to ensure their

to provide women with the morning-after pill in

advice is tailored to the needs of the patient in front

advance of need – a campaign which attracted

of them.

front-page headlines across the British Press. In the UK, abortions must be carried out within the framework set down by the 1967 Abortion Act (as modified by the 1990 Human Fertilisation and

John Hancock

Embryology Act) except in Northern Ireland where

Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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SPECIAL REPORT: ABORTION SERVICES

Is Abortion and Contraception Policy Meeting Women’s Needs? bpas

Abortion has been much in the news in recent months, and often in ways that have generated more heat than light. As Britain’s largest single abortion provider, caring for 55,000 women with unintended pregnancies each year, bpas actively campaigns for ways to improve the abortion service, from bringing the law regulating the ‘abortion pill’ in line with practice in other developed countries to working with NHS hospitals and other providers to ensure that women with challenging medical conditions or whose pregnancy is later in gestation, are able to access the care that they need. From improvements in contraceptive services to the development of more sensitive care pathways for women seeking abortion for fetal abnormality, bpas promotes discussion about the many things that could be done to help women prevent unwanted pregnancies and to give them access to the best care if they decide they need an abortion. Our 11 May conference, ‘Pills in Practice: Is abortion and contraception policy meeting women’s needs?’ brought together renowned speakers from Britain, Europe and America to discuss all these issues at the Royal Society of Medicine in London.1 The conference opened with a discussion by Ann Furedi, chief executive of bpas, on the ‘prospects and barriers’ facing Britain’s abortion service at the current time. Furedi began by noting that ‘Providing a good abortion service is not that difficult ... when politicians keep their noses out of it’. She went on to outline the ‘relatively reasonable’ policy framework around providers, including the Abortion Act 1967 (as amended by HFE Act 1990); regulation by the Department of Health and the Care Quality Commission; clinical guidelines; a commissioning framework; policy drivers; and public support.

Two Decades of Progress All this is the outcome, explained Furedi, of ‘two decades of progress’ in abortion provision, where abortion services have been publicly funded and a number innovations have been

made to improve the flexibility of the service and the experience of women accessing it, from nurse-led provision and localised early treatment services to the provision of choice of treatment method and the ability for women to self-refer into a service. This progress reflects a broader ‘cross-ideological consensus’ that women have a role in public life, sex is about more than procreation, contraception is not infallible, and that parenthood should be planned and wanted. The result has been an acceptance that abortion is a necessary backup to contraception – it remains stigmatised but also often considered a responsible course of action in a woman experiencing an unwanted pregnancy.

than you expect... Quick access to specialist sexual health services with excellent clinical outcomes. • Abortion services • Specialised booking services • Contraception • STI services • Health promotion and education

Barriers Remain So what are the barriers to continued improvement in abortion care? One recent development has been the emergence, in and around government, of a rather more negative view of abortion than that which has prevailed in policy circles over the past two decades. This has been illustrated by politically-motivated attempts to undermine the credibility of abortion clinics and their staff, and to trivialise women’s reasons for needing abortion. This was epitomised by the decision by the Health Secretary, Andrew Lansley, in March to instruct the Care Quality Commission (CQC) to carry out a series of ‘unannounced inspections’ on abortion clinics throughout the UK to ensure that doctors are complying with the ‘spirit and the letter’ of the 1967 Abortion Act.2 This was allegedly a response to concerns that some doctors might be ‘pre-signing’ the HSA1 abortion forms. The law states that, except in emergencies, two doctors must certify an abortion after reviewing the necessary clinical information about the woman’s case, which could have been taken by another doctor or nurse. There is no requirement for them to have actually seen the woman. Lansley’s concern was that this ‘second signature’ is being provided before the doctor has reviewed the relevant

08457 30 40 30 www.bpas.org development@bpas.org

As a registered charity (number 289145) all surplus generated by providing bpas’ services is reinvested to further improve services in the UK.

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SPECIAL REPORT: ABORTION SERVICES

Abortion is a necessary back-up to contraception – it remains stigmatised but also often considered a responsible course of action in a woman experiencing an unwanted pregnancy.

BPAS CONSULTATION

notes. This is not the practice of most abortion providers, including bpas. At the time of writing, the results of these CQC inspections have not yet been released. The second doctor’s signature has been long understood to be a legal, rather than a clinical, safeguard; arising from attempts in the 1960s to pass a controversial new law in the form of the Abortion Act. As such, many politicians – including Lansley himself – have questioned whether it is necessary to retain this cumbersome and clinically irrelevant requirement in the 21st century. To divert the CQC away from its priority of checking for clinical safety across the health service as a whole towards an exercise designed to test legal compliance seemed like an unusual use of resources. Indeed, the CQC itself complained that these checks cost £1 million, and meant that 580 pre-planned inspections had to be cancelled.3

There Are Still Those Who Argue Against Abortion Counselling Beyond the CQC inspections, there have been other signs that the political climate in Britain is becoming increasingly unfavourable to the clinics that provide abortions and the women who need them. The Department of Health is currently conducting a consultation on abortion counselling, which arose in response to the failed attempt by Nadine Dorries, the noted anti-abortion MP for Mid Bedfordshire, to pass a parliamentary amendment to the Health and Social Care Bill that would strip abortion providers of the ability to provide women with information, advice and counselling.4 4 | WWW.PRIMARYCAREREPORTS.CO.UK

The ‘counselling consultation’ does not seem to be based on any actual evidence of a problem with abortion counselling, which has been provided by clinics for many years and has been established in this way for very good reasons. Most people imagined that the spectacular defeat of the Dorries amendment in Parliament would have indicated that our elected representatives did not wish to spend time and money on reorganising a well-functioning service for the sake of it, yet this appears not to be the case.

The ‘Abortion Pill’ – Still Not For Home Use in Britain Where policymakers really could make a positive improvement to abortion provision, they have dug their heels in and refused to allow practice in Britain to be brought into line with the rest of the world. This was exemplified back in January 2011, when Department of Health lawyers aggressively – and successfully – fought a High Court challenge brought by bpas, which argued for an interpretation of the Abortion Act that would allow women to take misoprostol, the second medication involved in Early Medical Abortion (the ‘abortion pill’) at home. The practice of ‘home use’ of misoprostol is standard in many other countries, including the USA; and at the May ‘Pills in Practice’ conference Beverly Winikoff, President of Gynuity Health Projects in the USA, outlined the innovations and improvements that have been made in that country with medical abortion in the early stages of pregnancy. Essentially, the ‘abortion pill’ – a combination of the drugs mifepristone and misoprostol, which need to

SPECIAL REPORT: ABORTION SERVICES

be taken 24-48 hours apart – has allowed for a significant ‘demedicalisation’ of abortion for women with pregnancies of under 9 weeks. The service is nurse-led, and the abortion itself can be woman-led – to the extent that where women are permitted to take one or even both of the drugs home with them, they can ‘time’ their abortion around what best suits them; for example, weekends or when their partner is home from work to take care of the children. The Early Medical Abortion regimen has demonstrable ability to allow terminations to be provided earlier in gestation, at greater ease and convenience for women and making full use of the skills of nurses and midwives. It seems increasingly bizarre that British abortion providers are prevented from following these opportunities through enforced adherence to a law developed to regulate clinical practice of the 1960s, where abortions were surgical operations that had to be performed by doctors within a hospital setting.

Countering Protestors Another consequence of the current political climate has been an increase in the intensity of anti-abortion protest. On the doorsteps of abortion clinics, anti-abortion protestors have been adopting increasingly aggressive tactics in their desire to prevent women from accessing abortions.5 bpas has raised awareness of this problem in the media, and has been proactive in seeking ways to counteract the negative consequences of hostility to abortion. In this spirit, we are providing 15 placements for medical students seeking experience of abortion work, which will be funded by the US organisation Medical Students for Choice. After the scheme was reported by the Guardian newspaper and the British Medical Journal,6 we have been inundated with requests – indicating that there is plenty of scope for an organisation that believes in women’s choice to attract the doctors that Britain’s abortion service so badly needs.

Obstacles Remain in Obtaining Advice As for preventing unwanted pregnancy – how can contraception policy best meet the needs of British women? In May, a survey of our clients found that around 40 per cent of the 3,000 women with unwanted pregnancies who have used bpas’ contraceptive counselling telephone service since last year have reported problems with contraceptive access from GP practices and Contraception and Sexual Health (CaSH) clinics. These include clinic closures,

reduced opening hours that are inconvenient for working women, and restrictions on methods available. The findings support a recent audit by the Advisory Group on Contraception7 on services in England, which found that nearly a third of women aged 15-44 do not have access to fully comprehensive contraceptive services, through community or primary care. It found areas where the number of GP practices funded to fit intrauterine devices (coils) had fallen by half in the course of a year, restrictions on older women obtaining contraceptive pills from CaSH clinics, as well as PCTs reluctant to put local sexual health strategies in place until the Government releases its own strategy. It also found that those PCTs restricting access to contraceptives or contraceptive services had a higher abortion rate than the national average. In response to these findings, bpas called on the government to publish its long-delayed Sexual Health Strategy. Ann Furedi said: ‘There has been much government focus on “problems” with abortion services, despite evidence that women receive high quality care when faced with an unplanned pregnancy. At the same time, real and pressing problems with women’s access to the contraception they need to protect themselves from unwanted pregnancy in the first place appear low down the list of government priorities. Women need access to high-quality contraceptive services that are not restricted on the basis of age or location, with straightforward access to abortion care when their method lets them down.’

Bpas is Awarded ‘Adult Sexual Health Service/ Project of the Year’ Fortunately for women, bpas has the imagination to fill some of the gaps in contraceptive provision where it can. Of all the abortion-related headlines of the past six months, the most were gained by bpas’s Christmas initiative to provide women with the morning-after pill in advance of need.8 Women simply needed to have a telephone conversation with a specialist nurse, reducing the time and embarrassment that can be caused by requesting the emergency contraceptive pill from a doctor or pharmacy, and the pill would be posted to them. As our campaign attracted front-page headlines across the British press, we were again inundated with requests from women who thought this was an extremely good idea. And in recognition of that fact, the Brook/fpa Sexual Health Awards gave our scheme the award for the ‘Adult sexual health service/project of the year’.

08457 30 40 30 www.bpas.org development@bpas.org

As a registered charity (number 289145) all surplus generated by providing bpas’ services is reinvested to further improve services in the UK.

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SPECIAL REPORT: ABORTION SERVICES

On the doorsteps of

References

abortion clinics, anti-

2 Abortion clinics get spot-checks. BBC News Online, 23 March 2012 www.bbc.co.uk/news/health-17474191 Abortion clinic checks cost £1m. BBC News Online, 5 April 2012 www.bbc.co.uk/news/health-17620641

abortion protestors have been adopting increasingly aggressive tactics in their desire to prevent women from accessing abortions.

1. See the conference website for details: www.futureofabortion.org

3 Abortion clinic checks cost £1m. BBC News Online, 5 April 2012 www.bbc.co.uk/news/health-17620641 4 For a discussion of the Dorries amendment, see the bpas briefing ‘Abortion Providers and Pregnancy Advice’, published on Abortion Review, 29 June 2011 www.abortionreview.org/index.php/site/article/994/ 5 Anti-abortionists grow bold after making friends in high places. Guardian, 23 March 2012 www.guardian.co.uk/world/2012/mar/23/anti-abortionists-grow-bold?newsfeed=true 6 US charity to fund abortion training for British medical students. Guardian, 6 April 2012 www.guardian.co.uk/world/2012/apr/06/americans-fund-uk-abortion-training Abortion care programme for students launches in summer. Student BMJ 2012;20:e2409; 4 April 2012 http://student.bmj.com/student/view-article.html?id=sbmj.e2409 7 Advisory Group on Contraception http://cleregolfserver.co.uk/bayer/sex-lives-and-commissioning/index.html 8 See the BPAS blog: Taking stock of the morning-after pill, by Clare Murphy. Abortion Review, 11 January 2012 www.abortionreview.org/index.php/site/article/1092/

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SPECIAL REPORT: ABORTION SERVICES

Abortion, the Law and the GP John Hancock

GPs are human with a range of attitudes to abortion but the law is the law and clinicians have an obligation to ensure it is applied

The Abortion Act Today Laws on abortion, inasmuch as they attempt to reflect views on what remains a very controversial topic, vary widely from jurisdiction to jurisdiction and even within countries where the law tries to take account of regional variations in attitude. In the United Kingdom, the law that established a legal basis for the termination of pregnancies was the 1967 Abortion Act1 and that remains largely the law today. Any amendments have reflected changes in medical capabilities or attitudes towards the use of embryos for medical research and with guidance notes in England, Wales and Scotland. In Northern Ireland, reflecting particular local societal and religious-based factors, the Offences Against the Persons Act 18612 still applies and abortions are effectively illegal except where a pregnant woman is at real risk of death as a result of her pregnancy. In essence, the 1967 Act, as it stands today, allows for a pregnancy to be terminated… … by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:a) That the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or b) That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or c) That the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or d) That there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped. The term at which a pregnancy could be terminated was originally 28 weeks which was reduced to 24 weeks in the UK’s 1990 Human Fertilisation and Embryology Act 3

along with a number of other changes to the law on using embryos and embryonic material in medical research. There have also been further amendments to the law in 2002 and 2008 – check DH abortion website for details. Also, according to NHS Choices, ‘The law states that a doctor can refuse to certify a woman for an abortion if they have a moral objection to abortion. [However,] If this is the case, they should recommend another doctor who is willing to help4.’

GPs on the Front Line As the first clinician that many women would contact at the outset of pregnancy, General Practitioners have a particularly important responsibility in the area of pregnancy and abortion. For many GPs there is a balance to be achieved between their personal feelings and their professional duty to a patient. Some of the responses to the Marie Stopes ‘General Practitioners: attitudes to abortion 2007’ survey illustrate this necessary balance. As one respondent put it: “Although I personally disapprove of abortion I can see that it has a place in society and I would not prejudice my patients by refusing to help. I openly discuss the options and the psychological impact it may have. Most women do not take the discussion lightly5.” Of one thing there is no doubt, as ‘netdoctor’ puts it; “Terminating a pregnancy is a major decision and an extremely difficult one to make. It is advisable that the woman discusses her concerns with someone close who she can trust. For instance, it is often a good idea to consult your GP if you are pregnant and do not want to continue with the pregnancy6.” There is also the matter of women’s rights. In the Royal College of General Practitioners (RCGP) ‘Position Statement on Abortion’ it is clearly expressed that, “… Healthcare providers of abortion services should be committed to ensuring that women can access abortion services as early as possible to reduce the possibility of associated health risks7…”

08457 30 40 30 www.bpas.org development@bpas.org

As a registered charity (number 289145) all surplus generated by providing bpas’ services is reinvested to further improve services in the UK.

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SPECIAL REPORT: ABORTION SERVICES

The term at which a pregnancy could be terminated was originally 28 weeks which was reduced to 24 weeks in the UK’s 1990 Human Fertilisation and Embryology Act along with a number of other changes to the law.

BPAS CONTRACEPTIVE COUNSELLING

Requirements and Obligations Over and above these pastoral responsibilities and moral issues, doctors have a number of legal and procedural responsibilities in respect of the termination of pregnancies. For instance, because a responsible state has to maintain records, the Department of Health confirms that, “Registered medical practitioners are legally required to notify the Chief Medical Officer (CMO) of every abortion performed8.” It is very important that GPs work strictly within the letter of the law, especially, in this case, to the conditions under which abortions can be carried out. If those conditions are not met, then abortion remains a criminal offence under the Offences Against the Persons Act 1861. In order to reinforce this point and to clarify those conditions, Professor Dame Sally C Davies, Chief Medical Officer (CMO) wrote in February 2012 to Medical Directors of NHS and Primary Care Trusts and to independent sector abortion clinics setting out the conditions and requirements that must be met for an abortion to be legal under the 1967 Act9.

Plenty of Guidance Available When the Marie Stopes 2007 survey asked GPs, “Do you feel that the 1967 Abortion Act places an unreasonable burden of responsibility on the general practitioner?” The majority (72.5%) of those who responded felt that was not the case. The process is well set out with the doctor examining the [pregnant] woman to determine how long she has been pregnant and also to tell her about the options [for] termination and the risks involved. The doctor will send this 8 | WWW.PRIMARYCAREREPORTS.CO.UK

request to a hospital or clinic which will then make an appointment for the termination to be performed10. Because a significant number of women who choose to terminate a pregnancy are also young people, the GP must also take into account particular issues that can arise when dealing with this group. In a 2004 paper, “Best practice guidance…” The Department of Health set out some of the special concerns and methods that GPs need to use when dealing with younger people11. In a similar vein, the accompanying paperwork has to be properly completed, not only to maintain the statistics but also, for the GP’s protection, as an ‘audit trail’ to which anybody with an interest in a case can refer at a later date. There are a several forms involved and, once again, the Department of Health has issued a guidance, ‘Introduction to completing abortion forms12…’ The bottom line for GPs is that, whatever their own views, they have to work within the current UK law, even if that means referring a patient to another doctor. As the RCGP Position Statement… explains; “It is important that GPs recognise their duties and obligations in this area, which can raise personal ethical issues for a practitioner… While the opinions and feelings of others will often form part of the picture for each woman, the decision remains hers… All practices should have a clear written statement about how women who wish to discuss this issue can access appropriate practitioners within their practices13.”

SPECIAL REPORT: ABORTION SERVICES

The Interests of the Foetus Peter Dunwell, Medical Correspondent

A major consideration in determining the progress of a pregnancy is the future prognosis and likely outcome for the unborn child

To put it in straightforward terms, as NHS Choices does, “An abortion is the medical process of ending a pregnancy so that it does not result in the birth of a baby 14.” Whether that is by taking a pill or by a surgical procedure, abortion or termination of pregnancy entails the destruction of a foetus. There are a number of considerations for the unborn child that a GP should apply when guiding a pregnant woman.

Term into Pregnancy The first consideration is the term that the pregnancy has run. However, there are many views on the starting point for life, ranging from the Roman Catholic Church’s view that life begins at the point of conception, to the other extreme where, admittedly, only a few would argue that the foetus does not become human until birth. In between these two extremes, philosophers, scientists and clinicians have tried to establish a generally agreed point when the foetus acquires humanity; no easy task. For instance, is it about one week after conception when the fertilised egg is implanted in the womb or nearly four months later when the foetus first moves; is it when different foetal tissue develops for its different lifetime purposes (but that happens over a period of time), when brain activity can first be detected or when the foetus could survive outside of the womb? Even doctors honestly differ on this matter. For instance, in responses to the Marie Stopes survey15 question about the time limit on abortion; while one respondent reported that, “Due to the anomaly [of] scanning often not being done until 22 weeks, the Abortion Act should stay as it is [with a limit at 24 weeks].” another said: “My pragmatic sort of view is that in the first trimester the pregnancy is embryonic and not the same as a baby [at] 20 weeks [which equals a] small baby and increasingly should be considered to have rights.” In the end, for most countries and certainly for the UK, it has fallen to legislators (albeit with an eye to science) to establish a point at which viable human existence outside of the womb is deemed possible; and even that is affected by developing medical capabilities. So, when

the 1967 Act was passed, the term at which the foetus was considered capable of maintaining viable human existence outside of the womb was 28 weeks whereas, with advances in medical capability, that term was deemed as 24 weeks by the 1990 Human Fertilisation and Embryology Act. Most UK hospitals and clinics will not consider termination beyond 18 to 20 weeks16; not only in consideration of the viability of the foetus but also because the later an abortion is carried out, the more risk there is for the woman.

Disabilities and Abnormalities But beyond the gestational timeline, the law allows other considerations to be taken into account concerning the welfare of the foetus. For instance there may be occasions when families carry and transmit genetic abnormalities that might make the future child’s life either unviable or of an unacceptably low quality. This is a rare situation and a family’s GP would normally know whether this might be a risk. A more likely issue is whether the future child might be going to suffer disabilities or abnormalities. The U.K.’s 1967 Abortion Act allowed for termination of a pregnancy at any time if there was a significant risk of the baby being born seriously disabled and, given the advances in screening technology since 1967, it is usually possible to ascertain this risk quite early in the pregnancy17.

Other Conditions It is also possible for the foetus, while still in the womb, to develop tumours which can adversely affect development to full term and where, according to the National Institute for Health and Clinical Excellence (NICE), in most cases, the prognosis is poor18. In such cases, while not the only option, termination of the pregnancy is often considered the best outcome for the foetus and safest for the woman. With conditions, such as foetal cardiac abnormalities, surgical capability has advanced to the point where operations immediately following birth or even in the womb are possible so that the GP’s task in guiding a woman is by no means an

08457 30 40 30 www.bpas.org development@bpas.org

As a registered charity (number 289145) all surplus generated by providing bpas’ services is reinvested to further improve services in the UK.

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SPECIAL REPORT: ABORTION SERVICES

The pregnant womanâ&#x20AC;&#x2122;s lifestyle will impact on the welfare of the unborn child. For instance, drug or alcohol abuse can have a detrimental effect on the foetus growing in her womb.

BPAS CONSULTATION

easy one. The welfare of the pregnant woman if any surgery were to be carried out before birth, and the likelihood of the baby, after birth, developing normally should be at the forefront of support for a woman facing a decision to terminate pregnancy.

Lifestyle The pregnant womanâ&#x20AC;&#x2122;s lifestyle will impact on the welfare of the unborn child. For instance, drug or alcohol abuse can have a detrimental effect on the foetus growing in her womb. While it is by no means certain that these effects would make the future child unviable, it might well mean that it would need considerable medical interventions throughout its life. Here we are moving into very difficult ethical territory because the fact that a child may need support is not necessarily a reason why the foetus should be aborted. 10 | WWW.PRIMARYCAREREPORTS.CO.UK

Nevertheless it may be that a woman with the kind of chaotic lifestyle often associated with drug and alcohol abuse will not really be able to nurture and develop a child to its fullest potential. Also, where a woman has abused drugs and/or has been sexually active with multiple partners there could be the risk of HIV infection. But, as the Royal College of General Practitioners (RCGP) makes clear, GPs face a number of obligations in respect of the privacy of their patients which may make some interventions or decisions in these circumstances more complicated19. Taking account of issues around the welfare of the foetus when discussing decisions about pregnancy is, possibly, one of the more challenging tasks for a GP: probably the best advice is to keep up with all the latest developments in the fields concerned.

SPECIAL REPORT: ABORTION SERVICES

Reasons for Decisions John Hancock

The decision to end a pregnancy is never easy but there can be a number of reasons behind the need to choose

Abortion might be right course of action for a number of reasons and NHS Choices offers advice in this area20.

Rights of the Woman Because abortion involves the foetus and the woman, it is not simply a medical or political matter but also impacts upon views about women’s rights and issues of what support society offers a woman whatever choice she makes between continuing and terminating a pregnancy. In fact, the women’s rights approach cuts both ways, with some arguing the right for a woman to choose what happens to her body while others would claim that abortion conveniently sweeps under the carpet the real issues behind unwanted pregnancies21.

Practical Considerations However, to avoid this matter falling into a too philosophical style, we can consider the reasons for abortion in three main categories: the welfare of the mother (a subject in its own right and dealt with elsewhere this paper) economic pressures and social factors. In a country like the UK, the economic consideration in an abortion decision is not a strong one. One of the primary aims of the welfare state is to ensure that a child does not suffer any avoidable disadvantage as a result of its parents’ economic circumstances. Therefore the state, on behalf the society, is able to deploy a range of benefits and support services to address family economic needs. More often cited are social factors in the broadest sense of the term. The age of the pregnant woman can be a factor at either end of the spectrum. Where a girl becomes pregnant at a very young age, it may be that her body is not really able to cope with the rigours of pregnancy and childbirth while she is also mentally and intellectually ill-equipped to be a mother. At the other end of the age scale, as a woman becomes older the physical strain of pregnancy and childbirth is again an issue as well as the increased statistical probability of any child being born with a condition such as Down’s Syndrome plus, of course, the sheer physical strain of long-term motherhood in later

years. Scientific advances have complicated this matter as, in some countries, women well past natural childbearing years are able to become pregnant through IVF treatment.

Social Considerations Equally the likely ability of the parent or parents to be able to nurture and bring up a child is often a factor in decisions about pregnancy and abortion. Where the pregnant woman or potential parents themselves have issues such as ESN or specific health problems, it may be considered that the addition of a child would bring about a serious deterioration in the parents’ situation. And some relationships may not be considered conducive to providing a stable loving or nurturing home for children, often because the people involved have what is euphemistically called a ‘chaotic’ lifestyle. A very good example of this issue was illustrated in an article in the Guardian newspaper in May 201122. The writer commences her article … “I had an abortion in June 2008 when I was 24. I was with my long-term partner, though we were not living together. I was at the time working part-time, and had depression after my mother’s death the year before. My partner was on a minimum wage income, neither of us owned our own home, I was in fact living in a squat, and both of us were substance dependent. For these reasons I decided to terminate my pregnancy; having the baby was never a consideration for me.”

Boy or Girl One issue that UK doctors are more often exposed to these days is the matter of gender selection. This is particularly prevalent in nonindigenous communities with cultural roots in places where, for sociological and economic reasons, parents prefer boys and, where they can establish the gender of a foetus, may wish to abort a female foetus. Even in countries where this cultural trait may be prevalent it is usually illegal and, certainly in the UK, gender selection is not a valid reason for abortion. Nevertheless, GPs need be alert to the possibility that couples from some communities may well try to engineer

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Some relationships may not be considered conducive to providing a stable loving or nurturing home for children, often because the people involved have what is euphemistically called a ‘chaotic’ lifestyle.

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conditions for an abortion for this reason. On the other side, a lot of people from, say, the Indian community where this is an issue, would argue that it is not a gender but an economic matter; that girls not only cost the family more when they marry but also contribute no economic value thereafter. Again, this is not true in the UK but has to be addressed.

Alternatives In the first instance, the Royal College of General Practitioners (RCGP) believes that any woman seeking abortion should be offered counselling to ensure that her decision is well founded23. This, though, needs to be fast in order to avoid the woman falling outside of the 24 week limit for abortion in UK law. And at the 2012 conference, the British Medical Association (BMA) voted in favour of a system of unbiased 12 | WWW.PRIMARYCAREREPORTS.CO.UK

counselling from experts not connected with the clinics performing abortions.

Real Reasons Sometimes, mothers might try to disguise their real motives for seeking abortion and GPs need to be aware of the possibilities that an abortion may simply be requested when a pregnancy is inconveniently timed or as an alternative to contraception. In such cases counselling will be as important as clinical intervention. Overall, whatever the reasons that are given for seeking an abortion, the GP needs to understand what are the real underlying reasons and whether they might be better and more satisfactorily addressed from the woman’s point of view by a system of support and counselling or whether abortion really is the best decision.

SPECIAL REPORT: ABORTION SERVICES

Abortion is a People Issue Camilla Slade, Staff Writer

Whatever political or religious stances are taken on the subject, decisions about abortion affect the welfare of people, usually women

Not a Political Issue Arguments around abortion and women’s rights can become proxies for broader political positions. The BBC’s, generally balanced, coverage of this issue illustrates the point, “… since [risks associated with childbirth] is not a danger that men face, [to force it on women] would be a source of inequality and injustice24.”

Welfare While this may well be true, it does run the risk of taking what is a deeply personal matter and turning it into a general political issue. The factor at the heart of any discussion around abortion has to be welfare, the welfare of the unborn child (discussed elsewhere in this paper) and the welfare of the pregnant woman. The ‘netdoctor’ website explains: “The law states that two doctors need to agree that the abortion can be carried out. They will reach this decision if they believe there is a greater risk to the woman’s mental or physical health if she continues with the pregnancy than if she has an abortion25.” It is around this issue of the woman’s welfare that much of our current abortion legislation has been predicated. When abortion was illegal that didn’t mean that it didn’t happen: but because abortion was a crime, women resorted to ‘backstreet’ facilities run by unqualified people and which posed significant risks to the health of the women who used them, including suffering permanent physical damage and compromising their ability to bear children in the future. Worst of all, many women died as a result of these procedures. Even today’s abortion law can, some say, create unfair pressures on women and doctors. In the Marie Stopes International survey, ‘General Practitioners: attitudes to abortion 2007’ one respondent said of the current law, “The problem is GPs have to lie and say it is detrimental to mothers’ health. Actually it is social abortion…26”

Physical Risks Also, of course, it has to be borne in mind that any operation or procedure carries risks. In

the case of abortion, these are well understood by clinicians but need to be explained to the women concerned. There will most likely be bleeding after an abortion but that should cease in a couple of weeks with a normal period occurring five or six weeks after the procedure. Similarly it is not unusual to experience lower abdominal pain for one or two days following an abortion; this can normally be dealt with using normal painkillers. More seriously, if the womb has not been emptied properly or if during the procedure some infection occurred, the woman may develop vaginal discharge accompanied by higher temperature and abdominal pains. Such a pelvic inflammatory disease needs to be dealt with very quickly and may require a further procedure. Also there are rare occasions when the suction device used in an abortion may puncture the uterus which, if it occurs, could require the operation to be halted. It is unusual for infertility to result from a legal abortion carried out by a qualified doctor; but with a higher rate of sexually transmitted diseases in the UK, where a woman has chlamydia that is not treated before the abortion it can result in an inflammation of the fallopian tubes and ovaries which in turn will cause infertility.

Mental Risks Less discussed is the effect of an abortion on mental health. There is, of course, the matter of the immediate impact of the procedure, with the destruction or ejection of a foetus, and, on this matter, the Royal College of Psychiatrists has said that; “The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved27…” But there is also the longer term impact that might manifest when a woman is later in a position to have a child and will possibly be reminded of the unborn child that was aborted. The Royal College believes that a woman cannot give ‘informed consent’ to an abortion unless she has been properly apprised of the potential mental health risk.

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in circumstances where the woman has absolutely no choice, i.e. rape, it would be hard to argue that she should be made to continue with the pregnancy and the responsibilities that follow.

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Society Although some would say that the views of wider society should not circumscribe a woman’s right to make a decision on abortion, it cannot be ignored. Some religious groups have firm views on the subject and GPs from those groups may be influenced by those views. Some would not seek to impose their own faith on patients while others might refer patients on to those who could offer a less preformed view.

Conception One major issue that does play in these decisions is that of the circumstances around conception. For a variety of reasons, whether because they have not been taught or because they haven’t the intelligence or intellect to understand, some women don’t realise that sexual intercourse leads to pregnancy. Even where women do understand this reality there can be occasions when (often 14 | WWW.PRIMARYCAREREPORTS.CO.UK

with alcohol involved) that doesn’t help. Also there can be circumstances when a woman is taking proper precautions against becoming pregnant but those precautions fail. And then there is the very contentious issue of consent. Many would contend that a woman has the right to choose whether or not to become pregnant and that, by engaging in sex, she makes that choice. To then seek an abortion as a means of post-event contraception could be considered immoral. But in circumstances where the woman has absolutely no choice, i.e. rape, it would be hard to argue that she should be made to continue with the pregnancy and the responsibilities that follow childbirth, when this was something she never wanted. All in all, whatever the law and whatever the clinical factors, it cannot be ignored that at the heart of the abortion debate is the welfare of the people involved.

SPECIAL REPORT: ABORTION SERVICES

References: 1

UK 1967 Abortion Act http://www.legislation.gov.uk/ukpga/1967/87/section/1

RCGP Position Statement on Abortion http://www.rcgp.org.uk/pdf/RCGP%20Position%20Statement%20on%20Abortion.pdf

Wikipedia http://en.wikipedia.org/wiki/Abortion_Act_1967

NHS Choices http://www.nhs.uk/Conditions/Abortion/Pages/Introduction.aspx

Marie Stopes ‘General Practitioners: attitudes to abortion 2007’ http://www.mariestopes.org.uk/documents/GP%20attitudes%20to%20abortion%202007.pdf

netdoctor ‘What can be done about an unwanted pregnancy? http://www.netdoctor.co.uk/health_advice/facts/abortion.htm

RCGP Position Statement on Abortion http://www.rcgp.org.uk/pdf/RCGP%20Position%20Statement%20on%20Abortion.pdf

Department of Health, ‘Background to abortion notifications in England and Wales’ https://www.wp.dh.gov.uk/transparency/files/2012/05/A-Background-to-Abortion-Notifications-in-England-and-Wales.pdf

February 2012 letter from Professor Dame Sally C Davies, the Chief Medical Officer (CMO) and Chief Scientific Adviser http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132849.pdf

netdoctor ‘What can be done about an unwanted pregnancy?’ http://www.netdoctor.co.uk/health_advice/facts/abortion.htm

Department of Health http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4086914.pdf

Introduction to completing abortion forms for abortions performed in England and Wales http://transparency.dh.gov.uk/abortiontermination-of-pregnancy-in-england-and-wales/

RCGP Position Statement on Abortion http://www.rcgp.org.uk/pdf/RCGP%20Position%20Statement%20on%20Abortion.pdf

NHS Choices http://www.nhs.uk/Conditions/Abortion/Pages/Introduction.aspx

Marie Stopes ‘General Practitioners: attitudes to abortion 2007’ http://www.mariestopes.org.uk/documents/GP%20attitudes%20to%20abortion%202007.pdf

Netdoctor http://www.netdoctor.co.uk/health_advice/facts/abortion.htm

BBC website http://www.bbc.co.uk/ethics/abortion/medical/selective_1.shtml

NICE http://publications.nice.org.uk/percutaneous-laser-therapy-for-fetal-tumours-ipg180/the-procedure#indications

RCGP ‘Confidentiality and Young People’ http://www.rcgp.org.uk/PDF/CIRC_Confidentialityandyoungpeopletoolkit2.pdf

NHS Choices http://www.nhs.uk/Conditions/Abortion/Pages/Introduction.aspx

BBC website http://www.bbc.co.uk/ethics/abortion/mother/introduction.shtml

The Guardian http://www.guardian.co.uk/society/2011/may/12/abortion-reader

RCGP Position Statement on Abortion http://www.rcgp.org.uk/pdf/RCGP%20Position%20Statement%20on%20Abortion.pdf

BBC website http://www.bbc.co.uk/ethics/abortion/mother/safety.shtml

netdoctor http://www.netdoctor.co.uk/health_advice/facts/abortion.htm

Marie Stopes ‘General Practitioners: attitudes to abortion 2007’ http://www.mariestopes.org.uk/documents/GP%20attitudes%20to%20abortion%202007.pdf

Royal College of Psychiatrists www.rcpsych.ac.uk/.../NI%20response-termination%20of%20pregnancy%20 -%20080929.doc

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