The Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990)
(This briefing paper applies to Great Britain)
November 2007
Summary of the BMA's position on the Abortion Act
The BMA supports amending the Abortion Act 1967 so that, in the first trimester (up to 13 weeks):
- abortion is available on the same basis of informed consent as other treatment, without the need to meet specific medical criteria
- the requirement for two doctors to confirm that the abortion meets the legal criteria is removed.
- any changes in relation to first trimester abortion should not impact adversely on the availability of later abortions.
- any reduction in the current 24-week time limit
- the extension of nurses or midwives roles in abortion under the Act
- extending the current rules regarding “approved premises”.
The 24-week time limit for legal abortion
The BMA’s does not support any reduction in the current 24-week limit
When the 24-week limit was approved by Parliament in 1990, a key argument was that this was the stage at which the fetus was considered to be viable. It is the BMA’s view, based on the peer-reviewed published data available currently, that there is no evidence of significant improvements or advances in neonatal care, or understanding of fetal development, to suggest reducing the 24-week limit for legal abortion.
The BMA acknowledges that viability is difficult to define. It can be understood to mean that the fetus is capable of being born alive or, at the other extreme, that it is capable of surviving through childhood with no or minimal disabilities. The current legislative focus on viability has concentrated on gestational age alone. Factors such as birth weight, whether it is a multiple pregnancy and the gender of the fetus will also affect the outcome in any particular case 9go to reference 1). Even if a fetus reaches a gestational age which is considered the minimum possible for viability, many other factors come into play as to whether that particular fetus is or may be viable. Another relevant factor to consider in discussing viability therefore is whether “fetal viability” relates to the minimum stage possible for any fetus to survive, whether it refers to the viability of that individual fetus, or whether it refers to the stage at which the majority of infants may survive.
Even if a definition of viability can be agreed, data on “viability”, and particularly information that can be transferred to other units, can be difficult to obtain. This is because babies delivered at low gestations may not survive labour or past the delivery room. The data set therefore may be very small and the figures will have been obtained from different units which may have different policies in place, as well as variations in medical resources available, all of which will have an impact upon the results obtained.
Further information on the BMA’s position on the 24-week limit can be found at: http://www.bma.org.uk/ap.nsf/Content/abortiontime
First trimester (up to 13 weeks) abortion
The BMA supports amending the Abortion Act 1967 so that, in the first trimester: abortion is available on the same basis of informed consent as other treatment, without the need to meet specific medical criteria for abortions the requirement for two doctors to confirm that the abortion meets the legal criteria is removed.
It is the BMA’s view that where a woman has made up her mind to seek an abortion and meets the legal criteria, it is safer for the abortion to be carried out earlier in pregnancy rather than later, where this is an option. Earlier abortions result in a lower risk of complications, and are less traumatic for all concerned.
Removing the specific medical criteria
In light of clinical advances in inducing abortion, the requirement for a specific medical justification for an abortion in the first trimester is now unnecessary. Evidence shows that the risks involved in first trimester abortion are less than the risks associated with carrying a pregnancy to term. (Go to reference 2) For example, the risk of haemorrhage at the time of abortion is 0.88 in 1000 at less than 13 weeks’ gestation, rising to 4.0 in 1000 beyond 20 weeks’ gestation. (Go to reference 3).
In practice, few, if any, women will fail to meet the specific medical criteria in the first trimester under the current Act. Access to first trimester abortion should therefore be available on an informed consent basis as with other medical procedures. Women should be allowed to decide for themselves whether to continue an unwanted pregnancy in the first trimester, rather than having to demonstrate that they meet specific medical criteria.
This concept is accepted as the norm in many countries. The United Nations Population Division reports various countries where women do not need to satisfy medical criteria to end a pregnancy up to certain gestational limits (primarily the first trimester). The countries include Australia, Austria, Belgium, Canada, Denmark, France, Germany, Italy, Sweden and some parts of the USA. (Go to reference 4).
The need for two doctors’ signatures
Under the current Act, two registered medical practitioners must be of the opinion that an abortion can be performed on one of the grounds in the Act (except in emergency situations). The BMA’s view is that the need for two doctors to approve a termination is out of step with the increasing emphasis on patient autonomy in all other areas of medicine. Women make other important decisions concerning both their own health and that of their fetus without the need to involve two doctors and they should be given the same decision-making authority in relation to this aspect of their pregnancy. Furthermore, doctors do not need the protection of two signatures to show that the legal criteria for abortion are met under the Act as it can always be argued that women meet the current specified medical criteria in the first trimester.
Removing this condition from the legislation in the first trimester will remove one of the administrative burdens created by the Act that, in reality, does not stop women seeking abortion but potentially exposes them to delays and consequently higher risk and more costly procedures.
The requirement for two doctors’ opinions should be removed for abortions within the first trimester which would mean women being referred to the appropriate service without the specific forms required by statute.
Further information on the BMA’s position on first trimester abortions can be found at: http://www.bma.org.uk/ap.nsf/Content/Abortion-firsttrimesterabortions
Extending the role of nurses and the current rules relating to “approved premises”
The BMA does not support the extension of nurses’ or midwives’ roles in abortion under the Act, or extending the current rules regarding “approved premises”.
Clearly risk needs to be evaluated carefully prior to any change in the law. At the BMA’s 2007 annual conference, representatives voted against changing the law for first trimester abortions to extend the role of suitably trained healthcare professionals, including midwives and nurses, in abortion provision. A call to relax the current rules regarding “approved premises” in the first trimester was also rejected.
Doctors at the conference raised concerns that such changes might expose women to increased risks to their health, particularly if a woman encountered problems during the termination which required further surgical intervention, for example, a laparotomy.
Serious abnormality
It is difficult to provide a clear definition of serious abnormality. There needs to be sufficient flexibility to take account of individual cases. In providing guidance to doctors, the BMA lists the following factors that might be taken into account in assessing the seriousness of a handicap:
- the probability of effective treatment, either in utero or after birth
- the child’s probable potential for self-awareness and potential ability to communicate with others
- the suffering that would be experienced by the child when born
- the impact on the family. (Go to reference 5)
The BMA represents members with a wide range of views on abortion and has clear democratic and representative mechanisms for formally establishing policy on such issues through its annual conference (the Annual Representative Meeting, ARM). As the BMA’s policy-making procedure has been raised publicly, this section clarifies the democratic procedures by which motions are submitted, debated and voted on at the ARM.
The ARM agenda usually includes some 800 motions and it is therefore necessary to order and prioritise issues to ensure that the meeting runs effectively. This task is undertaken by the ARM Agenda Committee which is democratically elected each year. The Chairman of Conference chairs the Agenda Committee.
Many motions on the agenda are similar in wording and intent. They may reflect existing BMA policy, or there may have been a substantial debate at a recent ARM. The BMA had a substantial debate on abortion time limits at its 2005 conference, where a motion on the reduction of time limits was debated and overwhelmingly rejected. The ARM had not, however, discussed the issue of first trimester abortions. Therefore, priority at the 2007 conference was given to debating the issue of first trimester abortion.
The ARM agenda is published with the BMJ and on the BMA website, and is mailed to all ARM representatives (along with guidance on submitting alterations to the agenda) three weeks in advance of the conference. Representatives have the opportunity to submit amendments to the agenda in advance of the ARM. If a representative is unhappy with the order of the agenda or the motions which have been prioritised for debate, they have over three weeks to submit an amendment for consideration. A further opportunity is available for representatives who feel that an important issue is missing from agenda. They can submit an emergency motion. There is also a procedure when at the conference by which any motion on the agenda which is not prioritised can be voted as a “chosen motion” to which time is specifically allocated.
Background
The 1967 Abortion Act was based on a desire to end backstreet abortions. Prior to the Act many women underwent unsafe illegal abortions, which included the risk of death or subsequent infertility. The Act sets a range of conditions and safeguards in order for terminations to take place. It requires women to have a specific medical justification for an abortion (see below); a registered medical practitioner (a doctor) to administer it; and, except in emergency situations, two doctors to be of the opinion that the abortion meets the legal criteria, and the abortion to be administered in NHS or approved premises.
The Act, as amended by the Human Fertilisation and Embryology Act 1990, permits the termination of pregnancy up to 24 weeks’ gestation where two doctors have formed the opinion, in good faith, 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.”
In addition a pregnancy may be terminated up to birth where two doctors have formed the opinion, in good faith, that:
“the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
“the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
“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.”
In 2006, for women resident in England and Wales, (Go to references 6, 7) and Scotland (go to reference 8) the vast majority of abortions took place in the first trimester of pregnancy:
| Gestation | England and Wales (% of total performed) |
Gestation | Scotland (% of total performed) |
| Under 10 weeks | 68% | Under 10 weeks | 67% |
| 10-12 weeks | 22% | 10-13 weeks | 26% |
| 13-19 weeks | 9% | 14-17 weeks | 6% |
| 20 weeks and over | 1.5% | 18 weeks and over | 1% |
| 22 weeks and over | 0.7% | ||
| 24 weeks and over | less than 0.1% |
References:
- Draper ES, Manktelow B, Field DJ, James D. Prediction of survival for preterm births by weight and gestational age: retrospective population based study. BMJ 1999;319:1093–7 cited in: Royal College of Obstetricians and Gynaecologists. The investigation and management of the small-for-gestational-age fetus. Guideline no. 31. London: RCOG Press, November 2002;8.
- See for example: Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000-2002. London: RCOG Press, 2004; Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. London: RCOG Press, 2004; and Royal College of Obstetricians and Gynaecologists. Thromboprophylaxis during pregnancy, labour and after vaginal delivery, guideline no. 37. RCOG, 2007.
- Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. London: RCOG Press, 2004:8.
- United Nations Department of Economic and Social Affairs, Population Division. Abortion Policies: A Global Review. United Nations publication, 2003.
- British Medical Association. Medical Ethics Today. The BMA’s handbook of ethics and law. 2nd ed. London: BMJ Books, 2004: 242-3.
- Department of Health. Abortion statistics. England and Wales, 2006. Statistical Bulletin 2007/01. London: DH, 2007.
- Department of Health written evidence to the House of Commons Science and Technology Committee, September 2007.
- ISD Scotland. Scottish Health Statistics. Edinburgh: ISD Scotland, 2006.