Memorandum of evidence to the Science and Technology Committee Inquiry into the scientific developments relating to the Abortion Act 1967
August 2007
Executive summary
1. At the BMA’s Annual Representatives Meeting (ARM) in 2005, a detailed briefing paper on abortion time limits was prepared that considered published data on survival rates and the longer-term health of babies born at early gestation in the UK (go to reference 1). Doctors at the conference debated the issue, voted, and concluded that there should be no reduction in the current 24-week limit under the Abortion Act 1967.
2. The BMA believes that the Abortion Act 1967 should be amended so that first trimester abortion (abortions up to 13 weeks) is available on the same basis of informed consent as other treatment, and therefore without the need for two doctors’ signatures, and without the need to meet specified medical criteria. From a clinical perspective abortion is better carried out early in pregnancy. Given the relative risks of early abortion compared with pregnancy and childbirth, virtually all women seeking an abortion in the first trimester will meet the current criteria for abortion. The proposed amendment would help ensure that women seeking abortion are not exposed to delays, and consequently to later, more costly and higher risk procedures.
3. The BMA believes that any changes in relation to first trimester abortion should not adversely impact upon the availability of later abortions.
About the BMA:
4. The BMA is an independent trade union and voluntary professional association which represents doctors from all branches of medicine across the UK. It has a total membership of over 138,000. BMA policy is made at its ARM where motions are debated, and voted upon by locally, regionally and nationally chosen representatives after informed debate, with opportunities to hear all viewpoints.
5. The BMA welcomes the inquiry into the scientific developments relating to the Abortion Act 1967. We note that the Committee will not be looking at the ethical or moral issues and so we have limited our comments to clinical issues.
The 24-week time limit
6. In its 2005 briefing paper on abortion time limits, the BMA considered the peer-reviewed research on the survival rates and the longer term health of babies born at early gestation in the UK that was published in key journals. The two main studies were the EPICure and Trent health region studies. The Committee will no doubt receive information directly from those involved in the research but the following summary may be useful:
Trent health region study
This study looked at all European and Asian live births, stillbirths, and late fetal losses from 22 to 32 weeks’ gestation, excluding those with major congenital malformations. The original study considered live births, stillbirths and late fetal losses in women resident in the Trent health region between 1 January 1994 and 31 December 1997 (go to reference 2). The data were updated for the 4,112 births at 22-32 weeks’ gestation that took place between 1 January 1998 and 31 December 2001 (go to reference 3). Among this latter group, although survival rates varied depending upon birth weight, the overall probability of survival to discharge home was as follows:
|
22 weeks |
23 weeks |
24 weeks |
25 weeks |
European births |
7% |
15% |
29% |
47% |
Asian births |
3% |
11% |
27% |
51% |
The EPICure study
The EPICure study (go to reference 4) looked at the survival and later health status at 2½ and 6 years old of children born at 25 weeks or less gestation over a 10 month period in 1995 in the United Kingdom and Ireland. The following table is taken from data obtained from the study of the children at the age of 6 (go to reference 5).
| Summary of Outcomes among Extremely Preterm Children | ||||
Outcome |
22 weeks |
23 weeks |
24 weeks |
25weeks |
| Number (per cent) | ||||
Died in delivery room |
116 (84) |
110 (46) |
84 (22) |
67(16) |
Admitted for intensive care |
22 (16) |
131 (54) |
298 (78) |
357(84) |
Died in Neonatal Intensive Care Unit |
20 (14) |
105 (44) |
198 (52) |
171(40) |
Survived to discharge |
2 (1) |
26 (11) |
100 (26) |
186(44) |
Deaths post-discharge |
0 |
1 (0.4) |
2 (0.5) |
3(0.7) |
Lost to follow-up |
0 |
3 (1) |
25 (7) |
39(9) |
| At 6 years of age: | ||||
Survived with severe disability |
1 (0.7) |
5 (2) |
21 (5) |
26(6) |
Survived with moderate disability |
0 |
9 (4) |
16 (4) |
32(8) |
Survived with mild disability |
1 (0.7) |
5 (2) |
26 (7) |
51(12) |
Survived with no impairment |
0 |
3 (1) |
10 (3) |
35 (8) |
7. The BMA’s policy is that there should be no reduction in the current 24-week limit.
8. When the 24-week limit was agreed by Parliament in 1990, a key argument was that this was the stage at which the fetus was considered to be viable. It needs to be acknowledged that viability is difficult to define. For example, is it understood to mean simply 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 focused 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 (go to reference 6). 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.
9. 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, in addition, 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.
Serious abnormality
10. 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 7).
11. The BMA’s call to remove the specified medical criteria and the need for two doctors’ signatures is based partly on the view that risks of pregnancy and childbirth are invariably higher than the risks of early abortion, and women should be able to access earlier safer abortions without unnecessary barriers. We acknowledge that risk is complex to assess and can be considered in terms of numbers of risks, probability of risks and severity of risks. Making exact comparisons is difficult, but simply looking at the risk of death, a woman is more likely to die as a result of pregnancy and childbirth, than from terminating a pregnancy. Exact comparative figures are not possible to calculate on the data available but the data are indicative. In the Confidential enquiry into maternal and child health 2000-02 (the latest published figures), the maternal mortality rate due to direct and indirect causes (including following abortion) is 13.1 per 100,000 maternities for the UK (go to reference 8). Only five of the 391 maternal deaths reported occurred following abortion – a maternal mortality rate lower than 1 per 100,000 according to this single source of data as approximately 560,000 terminations took place in the UK between 2000-02 (go to reference 9). It is not clear from the enquiry report, even though cited in the “early pregnancy” section, when these deaths actually occurred as one is cited elsewhere in the report as occurring in the second trimester of pregnancy.
12. In addition, the earlier an abortion is carried out, the safer it is for women, with a lower risk of complications. It is also less traumatic for all concerned. 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 10).
13. These statistics reflect the fact that since 1967, there have been clinical advances in inducing abortion, particularly with regard to first trimester abortions and the introduction of medical abortions, ensuring that abortion is now much safer for women. The Royal College of Obstetricians and Gynaecologists (RCOG) states that women considering abortion should be given accurate information, for example, “that abortion is safer than continuing a pregnancy to term and that complications are uncommon” (go to reference 11).
14. Given that the evidence appears to suggest that virtually all women seeking an early termination of pregnancy will meet the specified medical criteria, it is highly questionable whether there is any benefit in requiring two doctors to confirm this fact.
15. Clearly risk needs to be evaluated carefully prior to any change in the law. At this year’s ARM, representatives voted against changing the law so that first trimester abortion could be carried out by suitably trained healthcare professionals, including midwives and nurses and relaxing the current rules relating to “approved premises” in the first trimester. Doctors at the conference raised concerns that such changes might expose women to increased risks to their health. The BMA does not, therefore, support the extension of nurses or midwives roles in abortion under the Act, or the removal of the rules regarding “approved premises”.
Long-term or acute adverse health outcomes
16. Controversy exists over the actual long-term psychological risks associated with abortion and whether women who do suffer psychological harm are more likely to have had a history of psychological problems prior to a termination. The RCOG states that:
“some studies suggest that rates of psychiatric illness or self-harm are higher among women who have had an abortion compared with women who give birth and to non-pregnant women of similar age. It must be borne in mind that these findings do not imply a causal association and may reflect continuation of pre-existing conditions (go to reference 12).”
17. Subsequent to the RCOG statement, a New Zealand study (go to reference 13) has been frequently cited as suggesting that there is a link between abortion and psychological harm. The study concludes, however, that “The findings suggest that abortion in young women may be associated with increased risks of mental health problems” [emphasis added], and in its discussion “There is clear need for further well-controlled studies…”. One of the study’s strengths is that it factors in other confounding factors that may have affected the women’s mental health, for example previous mental health and personality factors. There are limitations however, which mean that the study cannot be interpreted as clearly suggesting a link between abortion and psychological harm. The study makes no reference to the gestation of the women who had undergone abortion or the reason for the termination, amongst other things. These factors could be significant; it could be argued, for example, that the psychological impact on a woman terminating an unwanted pregnancy early on would significantly differ to a woman terminating a wanted pregnancy later on due to serious fetal abnormality or a risk to the mother’s life, or if the termination is a result of rape or incest; and yet these women are frequently grouped together.
18. Both abortion and mental health problems are common life experiences amongst women, and it is inevitable that there will be some overlap between these two groups. At least a third of women will have an abortion by the age of 45 (go to reference 14), and the World Health Organisation states that a quarter of people will suffer from mental and behavioural disorders at some time during their lives (go to reference 15).
19. There is also some evidence that women can die as a result of delays in accessing abortion services. The Confidential enquiry into maternal and child health 2000-02 found that “A very few women died because of administrative delays while waiting for therapeutic terminations of pregnancy that might have saved their lives” (go to reference 16).
References:
- This document can be made available to the Committee on request or can be found on the BMA website at http://bma.org.uk/ap.nsf/Content/AbortionTimeLimits. British Medical Association. Abortion time limits: a briefing paper from the British Medical Association. London: BMA, 2005.
- Draper E S, Manktelow B, Field D, James D. Prediction of survival for preterm births by weight and gestational age: retrospective population based study. BMJ 1999;319:1093-7.
- Updated data tables can be found at http://bmj.bmjjournals.com/cgi/content/full/319/7217/1093/DC1 (accessed on 1 August 2007).
- Costeloe K, Gibson AT, Marlow N, Wilkinson AR. The EPICure Study: Outcome to discharge from hospital for babies born at the threshold of viability. Pediatrics 2000;106(4):659-71; Wood N, Marlow N, Costeloe K, Gibson A, Wilkinson A, for the EPICure Study Group. Neurologic and Developmental Disability after Extremely Preterm Birth. N Engl J Med. 2000;343:378-84; Marlow N, Wolke D, Bracewell M, Samara M, for the EPICure Study Group. Neurologic and Developmental Disability at Six Years of Age after Extremely Preterm Birth. N Engl J Med 2005;352:9-19.
- Table taken from: Marlow N, Wolke D, Bracewell MA, Samara M for the EPICure Study Group. Neurologic and Developmental Disability at Six Years of Age after Extremely Preterm Birth. Op cit: 17.
- 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.
- British Medical Association Ethics Department. Medical Ethics Today. The BMA’s handbook of ethics and law. 2nd ed. London: BMJ Books, 2004: 242-3.
- Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000-2002. London: RCOG Press, 2004.
- Department of Health. Abortion statistics. England and Wales, 2005. Statistical Bulletin 2006/01. London: DH, 2006; and ISD Scotland. Scottish Health Statistics. Edinburgh: ISD Scotland, 2006.
- Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. London: RCOG Press, 2004:8.
- Ibid:29.
- Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. Op cit;9.
- Fergusson D M, Horwood L J, Ridder EM. Abortion in young women and subsequent mental health. Journal of Child psychology and psychiatry. 47(1);2006:16-24.
- Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. Op cit; 1
- World Health Organisation. The world health report 2001 - Mental Health: New Understanding, New Hope. Geneva: WHO, 2001:9
- Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000-2002. Op cit: 5.