After she resigned, Ms Abbott, the MP for Hackney North and Shoreditch, wrote in a letter to Ms Milton: “I entered into the meetings in good faith. I was genuinely interested in improving the quality of counselling available to women. But I now believe the ‘consultation’ will be a front for driving through the anti-choice lobbyists’ preferred option without legislation or a debate on the floor of the House.”

In a statement, Ms Abbott said there was “no doubt which option the government wants to drive through” on abortion counselling. “The talks that have taken place have been little more than window dressing for what is an aggressive, anti-choice campaign and I am walking away from them,” she said.

But Nadine Dorries, MP for Mid-Bedfordshire said her proposals had “almost no support” among its members and “overwhelmingly people around the table are opposed to what I’m trying to do”. She added that Ms Abbott had “no clue” about what had gone on at the group’s meetings because she had only attended two out of three events.

In a statement, Ms Milton said: “It’s disappointing when anyone walks away from constructive talks on such an important issue. Talks are continuing encompassing the wide range of views on abortion. I believe we have all been encouraged about how constructive they have been and how well the meetings are progressing.”

But Ann Furedi, chief executive of the charity BPAS, which provides abortions, said: “It is shocking that the minister and officials can disregard so blatantly the advice they have received from those who provide care to pursue the ideologically-driven demands of a handful of MPs who know nothing of how services are run - and have made no effort to find out.

“It is wrong for an important aspect of care to be politicised in this way. We are frankly stunned that officials can even consider dismantling the existing care-pathways which have developed in response to what women want and need, and that they have approved and regulated without any concern until Nadine Dorries tabled her amendment.”

MPs do not have to follow party lines on abortion, as it is considered an issue of conscience, BBC New Online reports.

Diane Abbott quits MPs’ abortion counselling group. BBC News Online, 26 January 2012

Also read:

Ministers press on with controversial abortion changes. Sunday Telegraph, 21 January 2012

bpas briefing: Abortion Providers and Pregnancy Advice. Abortion Review, 29 June 2011

Abortion Review topic archive: Abortion counselling

Critics of the existing system say the counselling which is offered by the clinics is biased, because their funding from the state depends on the number of terminations they carry out. The services deny bias - and say that sending women elsewhere could delay the process, meaning that for some a decision to end a pregnancy could come too late.

Last September, attempts to introduce such a change in Parliament failed, amid clashes between pro-choice and pro-life campaigners and within the Coalition.

The Government had indicated support for the amendment, tabled by Nadine Dorries, a backbench Conservative MP, but days before the vote, Downing Street said David Cameron said he would not back it.

The Liberal Democrats took credit for the apparent change of stance, with party sources saying Nick Clegg, their leader, had “made plain” his opposition. However, since then, Anne Milton, the health minister, has been working with DoH civil servants behind the scenes on plans to alter the system dramatically, the Sunday Telegraph reports.

Draft proposals will set out three options. The most radical change would see abortion clinics, such as those run by the British Pregnancy Advisory Service (BPAS) and Marie Stopes International, barred from providing counselling, and under a legal duty to refer women seeking it to an independent service - as had been laid out in Mrs Dorries’ amendment.

An second option is for a system of “voluntary registration”. This would would mean any organisation offering counselling to women with a crisis pregnancy would have to meet minimum standards, and only use appropriately-trained counsellors.

A cross-party group of 10 MPs which has held secret talks over the proposals has reportedly become deeply divided about whether organisations running such servicse should be required to declare any ethical stance - such as holding pro-life beliefs. If that demand is made, some pro-life campaigners are likely to argue that abortion clinics would have to declare a financial interest in carrying out terminations.

A third option, to retain the current, is also detailed in the DoH policy paper, despite claims that it would mean a “postcode lottery” remained in the standard of care.

Ministers are braced for fierce debate over the proposals, which are due to form a Department of Health consultation, likely to begin next month.

Mrs Dorries, who is on the cross-party group of MPs, said that the position reached was “an absolute victory for women” and that independent counselling would mean more support for the most vulnerable.

The MP said: “For the past fifty years, well educated, articulate women have known exactly what they want. They have accessed abortion, and been supported by friends and family - and for those women this will mean no change. For thousands of vulnerable women, the abortion decision is taken when overwhelming practical pressure meets emotional turmoil and this is why the offer of independent counselling is so important - as it is this group of women who will probably accept it.”

Frank Field, the Labour MP, who is also on the group, said he was keen to see a clear division made between services which carry out terminations, and those counselling women with crisis pregnancies. He said: “There is no other sphere of life in which we accept that the same people giving advice are those selling the product. We don’t do it with pensions, I cannot see how it is acceptable to do it with abortions.”

In August, the Sunday Telegraph disclosed the Government’s plans to consult on independent counselling for women contemplating abortion, just ahead of a Commons vote on an amendment by Mrs Dorries. Initially, the Government indicated support for the MP’s proposal - but this was withdrawn the week before the vote, following a backlash from pro-choice campaigners, abortion clinics, and Liberal Democrats, including Mr Clegg. In the Parliamentary debate, Frank Field withdrew his own support for the amendment.

Although votes on abortion are always treated as a matter of individual conscience, and subject to a free vote, pressure was then heaped on all Coaltion MPs to follow their leaders. In an unprecedented step, Mrs Milton wrote to them just days before the free vote, advising them that no health minister would back the amendment. The vote on the amendment was lost by 118 votes to 368.

Ann Furedi, chief executive of BPAS, said she was “appalled” to hear about the options which had been drawn up, and stated that she had been given repeated assurances from DoH officials that abortion clinics would not be barred from providing counselling services.

She said: “The point is that you cannot parcel out counselling; it needs to be something that is on offer at any stage when a woman considering ending or continuing a pregnancy might want it. My concern is that this whole situation has been politically driven, and that the consequences could be hugely damaging to the service which is provided to women.”

A spokesman for the DoH said: “Work is under way to develop proposals so women can access independent counselling but no decisions have yet been taken. It’s crucial that women considering an abortion get the best advice and support available so they can make the right decision for them. We will consult on this publicly later this year.”

Ministers press on with controversial abortion changes. Sunday Telegraph, 21 January 2012

Also read:

UK: Dorries amendment fails spectacularly. Abortion Review, 7 September 2011

bpas briefing: Abortion Providers and Pregnancy Advice. Abortion Review, 29 June 2011

Abortion Review topic archive: Abortion counselling

BCAP said the adverts would be allowed as long as they were not harmful, offensive or misleading. The new rules take effect on 30 April.

Pregnancy clinics that run on a not-for-profit basis are already allowed to advertise on television and radio.

In a statement, BCAP said existing rules on broadcast advertising would ensure general audiences were be robustly protected from harm or offence once the restrictions were removed. It said it held a full public consultation last year but did not receive any response from the Department for Culture, Media and Sport or the Department of Health.

Clinics which do not directly refer women for terminations will have to make that clear in their advertising under the new rules. The Committee of Advertising Practice (CAP) said this was on strong public health grounds. This follows concerns, reported in the Guardian last year, about the ways in which crisis pregnancy centres established by opponents of abortion can mislead women about the services they provide.

Spokesman Matt Wilson said: “There is not going to be some sort of free-for-all saying ‘Come to us to get an abortion’. They are not there to promote abortion, they have to promote an array of services. It is about being responsible, and commercial pro-life pregnancy services will now be able to advertise too.”

Darinka Aleksic, from the pro-choice group Abortion Rights, said: “Surveys tell us that fewer than half of the UK population know where to turn when they are faced with an unplanned pregnancy - apart from going to their GP - and a lot of women, especially young women, they’re not comfortable about talking to their regular GP about this. So it’s really important that they have access to objective, accurate information about all their options when they’re facing unplanned pregnancy and that includes parenting and adoption as well as abortion.”

However, Conservative MP Nadine Dorries said the move would make having a termination seem “as easy as having your lunch”.

“What this is actually going to do is desensitise what abortion is and the seriousness of it,” she told the Daily Mail. “That may be great for articulate, well-educated women who know exactly what they want but the more vulnerable woman who is in emotional turmoil is going to be badly damaged. Broadcasters will be making profit through advertising revenue off the back of a service which ends life. It’s appalling.”

Both pro-life and groups which offer abortion advice say this ruling will not see a surge of advertisements on television because more abortions are carried out by groups on behalf of the NHS. In 2010, 96% of abortions were funded by the NHS, 51% of which were carried out by independent clinics on behalf of the service.

The Society for the Protection of Unborn Children (SPUC), a pro-life group, said advertising would be dominated by groups such as the British Pregnancy Advisory Services (BPAS) and Marie Stopes as they receive funds from the NHS to carry out abortions. The group added that “Marie Stopes and their ilk” should have to declare that they offer abortion or have a financial interest in it. “This decision will only serve the abortion industry’s money-spinning trade which hurts women through killing their unborn children,” added a spokesman.

A spokeswoman for BPAS said: “Unlike anti-abortion agencies, BPAS believes that whatever decision a woman makes - be that to keep or end the pregnancy - is equally valid. We are a not-for-profit charity; our only interest is in a woman making the choice that is right for her.”

CAP and BCAP are responsible for the self-regulation of the advertising industry under the watch of the Advertising Standards Authority (ASA). In 2010, the ASA rejected complaints about the first UK television advertisement by an abortion advisory organisation. The advertising watchdog said the advert for Marie Stopes, which ran on Channel 4, did not mention or advocate abortion.

Abortion clinics cleared for TV by advertising body. BBC News Online, 21 January 2012

Television WILL screen pro-abortion adverts amid storm of controversy. Daily Mail, 21 January 2012

Post-conception advice services: Regulatory Statement. Committee of Advertising Practice , 20 January 2012

UK: Investigation into crisis pregnancy centres. Abortion Review, 8 August 2011

From a medical perspective, this term refers to modalities to induce fetal demise (1). Feticide is most commonly used for selective termination of higher order gestations to twins or singletons. It is also used by some providers before medical and surgical abortion in the second and third trimesters to avoid signs of life at induction or in the belief that it makes the procedure easier and safer. Several methods have been described including intra-cardiac injection of potassium chloride, intra-amniotic injection of digoxin, and transection of the umbilical cord (2). Older methods of medical abortion employed instillation of hyperosmolar solutions such as urea, which also variably induced fetal demise.

Q) When is feticide typically used in the abortion process?

In Britain, the Royal College of Obstetricians and Gynaecologists (RCOG) has made specific recommendations about the use of feticide before medical abortion in cases of fetal abnormality (3). Its recommendations have also been applied to medical abortions for other indications (4). According to the RCOG, because the rare likelihood of a live birth increases from 21+6 weeks of gestation, feticide should be routinely offered after this gestational age to avoid this possibility. The RCOG recommends the use of intra-cardiac potassium chloride to ensure fetal asystole, which can be observed ultrasonographically typically within minutes after injection.

The usefulness of feticide before dilatation and evacuation (D&E), the commonest method of surgical abortion in the second trimester, remains a matter of debate. Cervical preparation before D&E usually occurs in the 24-48 hours before surgical evacuation and extra-mural deliveries, although rare, have been reported. Induction of fetal demise in these cases would avoid the potential for a live birth. However, advocates of feticide typically propose that the maceration of the fetus which occurs as a result of demise is beneficial because it leads to an easier, faster and safer surgical evacuation (5).

The only randomised trial comparing feticide to placebo evaluated intraamniotic digoxin and used procedure duration as a proxy for ease of abortion. With 1mg intra-amniotic digoxin, there was no difference in procedure time (p=0.60) or difficulty as reported by the surgeon (p=0.64) (6). Although the study was not designed to assess clinical outcomes, there were no differences in estimated blood loss, pain scores or complications between the groups. There are no similar studies of potassium chloride or other methods of feticide.

Q) What are the clinical skills required to administer feticide?

Most feticidal procedures are performed by intra-cardiac or intra-amniotic injections. Ultrasound evaluation prior to either allows confirmation of gestational age, evaluation of amniotic fluid level, fetal position, and placental location. Continuous ultrasound guidance is not necessary for intra-amniotic injections as confirmation of location of the needle can be assessed by drawing up a small amount of amniotic fluid into a syringe before injection of the medication. Intra-fetal or intra-cardiac injection, however, requires a greater degree of precision in needle positioning and continuous ultrasound guidance is usually employed. Ultrasound is also useful to confirm fetal asystole following potassium chloride injection.

Q) What are the advantages of using feticide from a clinical point of view?

There is some limited evidence that induced fetal demise before a medical abortion shortens the interval been the onset of the induction and expulsion of the fetus (7). In the setting of placenta praevia, bleeding may be less when feticide has been administered prior to a medical abortion (8). These effects still require testing in the context of larger, randomised trials. The randomised trial of digoxin before D&E at 20-24 weeks gestation by Jackson et al (6) reported that 92% of participants expressed a strong preference for fetal demise before the abortion. However, of those, 29% believed the injection would make the procedure easier and 19% less painful for the woman having the abortion, neither of which were proven by this study.

Q) And the disadvantages?

Extra-mural delivery of the fetus can occur in the interval between administration of feticide and initiation of a medical or surgical abortion (2). Although signs of life are avoided this is distressing and, in the case of a planned D&E, not the outcome the woman desired. Potential complications include injection site pain, amnionitis, or sepsis. Digoxin is associated with vomiting as a common side effect. One case report of a maternal cardiac arrest has been reported following potassium chloride injection (9).

Q) What would you recommend as best practice in the use of feticide?

There is currently no evidence to support the use of digoxin to facilitate increased safety with dilatation and evacuation. There is, however, evidence that its administration has the potential to cause harm (e.g., infection, vomiting, extra-mural delivery). It has recently been argued that digoxin feticide before D&E should only be provided in the context of a clinical trial aimed at assessing its benefits (10). At BPAS, we routinely perform intra-cardiac potassium chloride injections before D&E at 22+0 weeks and greater. We regularly review complications with all of our procedures and have found that, empirically, this practice is associated with an extremely low rate of complications. However, it is unknown whether it is the feticide or some other aspect of our service delivery which leads to such a strong safety profile. Ideally, this practice should be studied in a randomised trial as well.

At present, the RCOG makes a strong recommendation for the routine offer of feticide before later medical abortions, which is centred around the avoidance of resuscitation that is counter to the objective of terminating a pregnancy. Whether the balance of risks and benefits sways toward fetcide from a clinical perspective remains unclear. In addition, little is known about how patients feel about undergoing this invasive procedure which may, in and of itself, be distressing. Best practice at this stage would be to call for more and better research on the use of feticide.

Read all Patricia Lohr’s Clinical Update columns here.

References

(1) R.H. Graham et al. Understanding feticide: An analytic review. Social Science & Medicine. 2008; 66:289–300
(2) Diedrich J, Drey E; Society of Family Planning. Induction of fetal demise before abortion. Contraception. 2010 Jun;81(6):462-73.
(3) RCOG. Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales. London: RCOG, 2010.
(4) RCOG. The Care of Women Requesting Induced Abortion: Evidence-based Clinical Guideline Number 7. London: RCOG, 23 November 2011
(5) Maureen Paul, Steve Lichtenberg, Lynn Borgatta, David A. Grimes, Philip G. Stubblefield, Mitchell D. Creinin, eds. Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care. Chichester, W. Surrey, UK: Wiley-Blackwell, 2009.
(6) Jackson RA, et al. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstetrics and Gynecology. 2001;97:471–476
(7) Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstetrics and Gynecology. 1999;94:139–141.
(8) Ruano R, et al. Second- and third-trimester therapeutic terminations of pregnancy in cases with complete placenta previa—does feticide decrease postdelivery maternal hemorrhage?. Fetal Diagnosis and Therapy. 2004;19:475–478.
(9) Coke GA, et al. Maternal cardiac arrest associated with attempted fetal injection of potassium chloride. International Journal of Obstetric Anesthesia. 2004;13:287–290
(10) Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion: Evidence and ethics. Contraception. 2011 May 26. [Epub ahead of print]

NHS Greater Glasgow and Clyde claims conscientious objections do not give them the right to refuse such duties.

The hearing, at the Court of Session in Edinburgh, continues.

Ms Doogan and Mrs Wood sought during a grievance procedure to have confirmation that they were not required to delegate, supervise or support staff in the participation and care of patients through “the processes of medical termination of pregnancy and feticide”. NHS Greater Glasgow and Clyde (GGC) rejected their application.

Both women have now gone to court seeking to have the ruling set aside in a judicial review, claiming that the refusal to recognise their entitlement to conscientious objection was unreasonable and violated their rights under Article 9 of the European Convention on Human Rights (ECHR) guaranteeing the right to freedom of thought, conscience and religion.

They are seeking a finding that their entitlement to conscientious objection to taking part in abortions in terms of the 1967 Abortion Act includes the right to refuse to delegate, supervise and support staff involved in such work.

The women said in their petition that they are practising Roman Catholics and: “They hold a religious belief that all human life is sacred from the moment of conception and that termination of pregnancy is a grave offence against human life.”

They maintain that they hold the belief that that their involvement in the process of termination is wrongful and an offence against God and the teachings of their church.

Ms Doogan and Mrs Wood, who are both midwifery sisters at the Southern General Hospital, in Glasgow, worked in the labour ward. Ms Doogan, from Glasgow, has been absent through ill health since 2010 as a result of the dispute, BBC News Online reports. Her colleague, from Clarkston, East Renfrewshire, has been transferred to maternity assessment work.

NHS GGC, which is contesting their action, said it recognised their right not to participate in terminations under the terms of the Abortion Act. But it maintains that it decided correctly that requiring them to delegate staff to nurse women undergoing medical terminations and to supervise and support staff undertaking that duty was lawful.

It maintains that the women’s rights to conscientious objection under the legislation does not include the right to refuse such duties. The board said that its decision respects the women’s rights under Article 9 of the ECHR.

Catholic midwives in abortion conscientious objection case. BBC News Online, 17 January 2012

The researchers also found that nearly half of all abortions worldwide are unsafe, and almost all unsafe abortions occur in the developing world. The study, ‘Induced Abortion: Incidence and Trends Worldwide from 1995 to 2008’, by Gilda Sedgh et al., was published online on 18 January by The Lancet.

In the developing world, the abortion rate was 29 per 1,000 in both 2003 and 2008, after falling from 34 per 1,000 between 1995 and 2003. The situation was somewhat different in the developed world, excluding Eastern Europe, where the abortion rate was much lower, at 17 per 1,000 in 2008, having declined slightly from a rate of 20 in 1995.

“The declining abortion trend we had seen globally has stalled, and we are also seeing a growing proportion of abortions occurring in developing countries, where the procedure is often clandestine and unsafe. This is cause for concern,” says Gilda Sedgh , lead author of the study and a senior researcher at the Guttmacher Institute. “This plateau coincides with a slowdown in contraceptive uptake. Without greater investment in quality family planning services, we can expect this trend to persist.”

Research from WHO shows that complications due to unsafe abortion continued to account for an estimated 13% of all maternal deaths worldwide in 2008; almost all of these deaths occurred in developing countries. Globally, unsafe abortion accounted for 220 deaths per 100,000 procedures in 2008, 350 times the rate associated with legal induced abortions in the United States (0.6 per 100,000). Unsafe abortion is also a significant cause of ill-health: Each year approximately 8.5 million women in developing countries experience abortion complications serious enough to require medical attention, and three million of them do not receive the needed care.

“Deaths and disability related to unsafe abortion are entirely preventable, and some progress has been made in developing regions. Africa is the exception, accounting for 17% of the developing world’s population of women of childbearing age but half of all unsafe abortion–related deaths,” notes Iqbal H. Shah, of the WHO and a coauthor of the study. “Within developing countries, risks are greatest for the poorest women. They have the least access to family planning services and are the most likely to suffer the negative consequences of an unsafe procedure. Poor women also have the least access to postabortion care, when they need treatment for complications.”

The findings provide further evidence that restrictive abortion laws are not associated with lower rates of abortion. For example, the 2008 abortion rate was 29 per 1,000 women of childbearing age in Africa and 32 per 1,000 in Latin America, regions where abortion is highly restricted in almost all countries. In contrast, in Western Europe, where abortion is generally permitted on broad grounds, the rate is 12.

The Southern Africa subregion, where close to 90% of women live under South Africa’s liberal abortion law, has the lowest abortion rate in Africa, at 15 per 1,000 women. Other very low subregional rates are found in Western Europe (12) and Northern Europe (17), where both abortion and contraception are widely available either for free or at very low cost.

Eastern Europe presents a very different situation, with an abortion rate that is nearly four times that of Western Europe. This discrepancy corresponds with Eastern Europe’s relatively low levels of modern contraceptive use and low prevalence of highly effective methods such as the pill and the IUD. After a striking decline in the abortion rate between 1995 and 2003, from 90 to 44 per 1,000 women, Eastern Europe experienced virtually no change in the rate between 2003 and 2008.

LONG-TERM WORLDWIDE DECLINE IN ABORTIONS HAS STALLED: Plateau Coincides with Slowdown in What Had Been a Steady Increase in Contraceptive Use. Guttmacher Institute, 18 January 2012

Induced abortion: incidence and trends worldwide from 1995 to 2008. Dr Gilda Sedgh, Susheela Singh, Iqbal H Shah, Elisabeth Åhman, Stanley K Henshaw, Akinrinola Bankole. The Lancet, Early Online Publication, 19 January 2012. doi:10.1016/S0140-6736(11)61786-8Cite or Link Using DOI

Facts on Induced Abortion Worldwide. Guttmacher Institute, January 2012

It was interesting to note the difference in response between the enthusiasm of the women who wanted to use the scheme (so many requests in the first 48 hours we couldn’t guarantee Xmas delivery) and that of officials, who were not so keen. The Health Secretary Andrew Lansley, who despite having his hands full with NHS reform, still found the time to express his opprobrium, noting that emergency contraception should be just ‘for emergencies, not everyday use’, and that ideally it would be available in person, so that ‘any decisions were made with the benefit of face-to-face advice’. 

It’s a bit odd to describe a woman requesting one solitary pill as someone who is planning on popping it daily - but there you go. What was however prevalent among the women who contacted us was that many had experienced difficulties obtaining the medication in the past, and appreciated being able to speak to someone over the phone who they knew was not judging them, but rather recognising that they were doing a sensible thing. They weren’t planning on being reckless, but wanted to ensure that they had immediate access to an effective way of protecting themselves against an unwanted pregnancy if they needed it. And they perhaps didn’t feel the need – or desire - for time-consuming ‘face-to-face advice’ about the decision whether or not to take the morning-after-pill should the situation arise.

You can’t help thinking that if we’d been offering Viagra free of charge to men in need we would have been slapped on the back, such is still the contradiction in attitudes towards male and female sexuality. Indeed it was interesting to compare the Telegraph’s outrage that a ‘penny-pinching NHS’ was curbing men’s sex lives by rationing erectile dysfunction drugs to two doses per month with its excoriating reaction the same week to our free morning-after pill scheme. That paper lined up no fewer than five critics, including Nadine Dorries MP, whom somehow we just can’t seem to please: she doesn’t like it when we are providing abortions, but appears equally aggrieved when we are trying to prevent the need.

The morning-after pill - much like long-acting reversible contraceptives (LARCs)- was never going to be a silver bullet to cut unwanted pregnancy. Many women do not know their contraception has failed, or believe they are at a time in their cycle when they are unlikely to get pregnant. But did we give up too quickly on it? We know that the cost, inconvenience and embarrassment of obtaining the morning-after pill can put women off obtaining it when they think their risk is low. Our own surveys show that women also worry about the health implications of using ECPs – even though post-coital contraceptives have been around for decades and there is no evidence of any long-term health consequences. But it is not surprising that women have reservations about using ECPs when all the messages around its use in this country have always been so very mixed: use it, but don’t ever need to use it.

This message needs to change. Research is currently being conducted in the USA into using post-coital contraception as a regular form of contraception for women who do not have frequent sex – a ‘before sex’ pill, if you like. It may well alter the narrative around ECP use, from being seen as something to be embarrassed about to becoming recognised as a planned, responsible, course of action. In the meantime, the morning-after pill should be viewed as a legitimate and welcome back-up for women to control their fertility as often as they need to, well deserving of its place on the contraceptive menu.

Are we making the most of the morning-after pill? This will be one of the topics for discussion at BPAS’s public conference ‘Pills in Practice: is contraception and abortion policy meeting women’s needs?’, on Friday 11 May 2012. For more information and to book a place please see here.

Read on:

UK: Morning-after pill offered free by post. Abortion Review, 6 December 2011

Pills in Practice: Is abortion and contraception policy meeting women’s needs? Announcing the BPAS public conference, to be held at the Royal Society of Medicine in central London on Friday 11 May 2012.

BPAS blog

On one hand, abortion and contraception have come a long way since the 1967 Abortion Act; services are legal, provided, and funded, and control over one’s fertility has become an accepted and expected part of life. On the other hand, the extent to which arcane laws and political prejudices prevent the best use of new methods is a source of continuing frustration to service providers, and causes anxiety and inconvenience for women.

Take the development of the ‘abortion pill’, in the form of the drugs mifepristone and misoprostol. This has transformed provision of early abortion across the world, from an operation requiring a trained surgeon and a hospital bed into a service that can be led by nurses and midwives and administered by women themselves in their own homes. In theory at least, women using this method can have greater control and autonomy over when and where they have an abortion. Throughout the USA and Europe early medical abortion is routinely provided outside of hospital settings, in clinics and GP surgeries, and new research into the use of telemedicine in the USA shows the possibility of even greater flexibility in providing a safe, effective and accessible service.

Yet in Britain, the law is interpreted such that women are denied even the possibility of taking the misprostol, the second drug in the abortion pill, at home, requiring them instead to make multiple trips to clinics and to time taking their medication around the schedules of providers, rather than their own needs. This situation is starkly out of step with clinical guidance, and with practice in other countries. The importance of women’s autonomy over childbirth has been recognised over the past few decades, and steps have been taken to ‘de-medicalise’ childbirth, through promoting midwife-led care and home birth where possible, so why should abortion be so different? Isn’t it time we made the most of the skills of nurses and midwives, and took seriously women’s desire to have more control over their own bodies?

While provision of abortion in the early stages of pregnancy to healthy women has undoubtedly improved, there is a group of women for whom access is complex and restricted. This includes women seeking an abortion on grounds of fetal anomaly, who might find themselves denied a choice of abortion method or stigmatised over the perceived severity of the anomalies in question, and women with particular health conditions or high BMI. How do we ensure that the abortion and contraception services take account of the needs and circumstances of all individual women?

Another focus of discussion at the 2012 conference will be new developments in Long-Acting Reversible Contraceptives (LARCs), which offer more effective, longer-term prevention of unintended pregnancy. These methods have numerous advantages to women who want to use them; but these methods have disadvantages and side-effects that mean they may not be the ‘magic bullet’ for reducing abortion rates, or teenage pregnancy, in the way that some policymakers seem to hope. In the meantime, new thinking in the provision of more established forms of hormonal contraception, such as the pill and the morning-after pill’, seems to have stalled. How do we assess the benefits and downsides of LARCs? What might women in the future expect from contraception?

Underlying all these issues are questions to do with clinical practice, political will, ethical arguments, and medical training. In Britain, as in many other countries where abortion has been legal for more than a generation, there is a gap between women’s expectations of a service they can access, and ongoing controversies at a political level. This gap is mirrored in the problems experienced in recruiting and training a new generation of abortion doctors, nurses and midwives, without whom abortion services cannot be run, or improved.

The first in a series of events planned by BPAS on the theme of ‘The Future of Fertility’, the ‘Pills in Practice’ conference will bring together clinicians and service providers from the UK, Europe and the USA to discuss improvements in contraception and abortion care, and barriers that remain to the development of a service that is genuinely fit for purpose.

For more information about the Pills in Practice conference, including a programe and speakers’ biographies, please see the conference website. Tickets can be purchased here.

This article appears in the Winter 2011 print edition of Abortion Review. Contents also include - Clinical Update: Feticide, by Patricia Lohr; BPAS blog: Anti-abortion protests, by Clare Murphy; News and Medical Digest, July-October 2011. Download this edition for free here. 

Of the 85 women undergoing selective reductions last year, 51 were reducing a pregnancy from twins to a single fetus, up from 30 four years before. There were also 20 abortions to reduce triplets to twins and nine procedures to take a pregnancy from triplets to a single fetus.

Separate figures from the Human Fertilisation and Embryology Authority show that almost one third of selective abortions carried out in 2009 involved pregnancies that were a result of fertility treatment, the Daily Telegraph reports.

Multiple pregnancies are more dangerous to both mother and fetus and the Department of Health said that about three quarters of the selective reductions were made on medical grounds. The risk of birth defects is about twice as high for multiple pregnancies and the babies are far more likely to be premature. Twins are four to six times more likely to suffer cerebral palsy, and they are also more likely to have impaired sight and heart defects.

Prof Richard Fleming, the scientific director of the Glasgow Centre for Reproductive Medicine, said:

“I would be surprised if multiple pregnancy through fertility treatment was not a significant component to the increase in selective reductions. One of the components within that is the health to the mother and health to the offspring as well – both are compromised by multiple pregnancy. The more complicated multiple pregnancies lie almost exclusively in the IVF domain. It’s a horrible decision to make but a very sensible one.”

Dr Peter Saunders, the chief executive of the Christian Medical Fellowship and a former surgeon, said:

“There is no doubt that the rising use of IVF has contributed to a rise in multiple pregnancies. If prospective parents are not willing to have twins then they should not be implanting more than one embryo at a time. Parental preference should never take precedence over the right to life of the unborn child.”

In 2010 there were 189,000 terminations in England and Wales. Women can apply for an abortion on medical grounds up to the point of birth.

Although selective abortions represent a small proportion of the total figure, they are often viewed as among the most controversial.

In recent years there has been a move to reduce the number of multiple pregnancies because of the risks. In the 1990s the HFEA, which regulated fertility clinics, issued guidance saying that no more than three embryos should be transferred at any one time. A lower limit of two embryos for women aged over 40 was issued in 2001. In recent years the HFEA campaigned to persuade parents and clinics to implant just one embryo at a time and set clinics a limit on the number of multiple pregnancies they could produce.

However despite the risks, many women undergoing fertility treatment remain keen to increase their chance of becoming pregnant by implanting more than one fetus, the Telegraph reports.

“Women are encouraged to have a single embryo implanted and then freeze any others,” said Susan Seenan, from the Fertility Network, a support group. “But if one of the embryos is poor quality or the woman is having treatment on the NHS or paying for it privately, they are likely to want to maximise their chances.”

A spokesman for the Department of Health defended the practice. “Over three quarters, 78 per cent, of the selective terminations were performed under ground E – that there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped,” he said.

“Multiple pregnancies are generally a greater risk to the mother and the babies. The risk is greater for twins than single babies but rises dramatically with three babies or more.”

Abortions to reduce multiple births on the rise. Daily Telegraph, 28 December 2011

The review was commissioned by the AOMRC and carried out by the National Collaborating Centre for Mental Health (NCCMH) at the Royal College of Psychiatrists.

The review’s Steering Group and the NCCMH carried out a systematic and comprehensive search of the literature and identified 180 potentially relevant studies published between 1990 and 2011. The Steering Group was careful to ensure only the best quality evidence was used, so all studies were subject to multiple quality assessments. In total, 44 papers were included in the review.

On the basis of the best evidence available, the Steering Group concluded that:

• Having an unwanted pregnancy is associated with an increased risk of mental health problems. However, the rates of mental health problems for women with an unwanted pregnancy are the same, whether they have an abortion or give birth.

• The most reliable predictor of post-abortion mental health problems is having a history of mental health problems. In other words, women who have had mental health problems before the abortion are at greater risk of mental health problems after the abortion.

• Some other factors may be associated with increased rates of post-abortion mental health problems, such as a woman having a negative attitude towards abortions in general, being under pressure from her partner to have an abortion, or experiencing other stressful life events.

Dr Roch Cantwell, a consultant perinatal psychiatrist and Chair of the Steering Group, said: “Our review shows that abortion is not associated with an increase in mental health problems. Women who are carrying an unwanted pregnancy should be reassured that current evidence shows they are no more likely to experience mental health problems if they decide to have an abortion than if they decide to give birth.”

Professor Tim Kendall, Director of the NCCMH and a member of the Steering Group, said: “This review has attempted to address the limitations of previous reviews of the relationship between abortion and mental health. We believe that we have used the best quality evidence available, and that this is the most comprehensive and detailed review of the mental health outcomes of induced abortion to date worldwide.”

Professor Sir Neil Douglas, Chairman of the AOMRC, said: “The Academy recognises that this is a complex and controversial area, where there have been many conflicting research findings. We welcome this extremely high-quality review from the NCCMH, and endorse its findings.”

The Steering Group recommends that future practice and research should focus on supporting all women who have an unwanted pregnancy.

A draft version of this review was published in April 2011.

AOMRC press release: Systematic review of induced abortion and women’s mental health published. 9 December 2011

Also read:

Commentary: Abortion is not a mental health problem. By Jennie Bristow. Abortion Review, 9 December 2011