First trimester abortion


August 2007

Note: Please see separate 2008 brief for the BMA's position on the abortion time limit

Summary of the BMA's position
It is the 40th anniversary of the Abortion Act this year. The original Act was based on a desire to end backstreet abortions and protect women against the potential harm of undergoing them, 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. For example, the Act requires women to have a medical justification for an abortion; a registered medical practitioner to administer it and two doctors to confirm the abortion meets the legal criteria.

In light of clinical advances in inducing abortion, particularly the introduction of medical abortion, the BMA considers some of these safeguards are no longer necessary to ensure the safe administration of abortion in the first trimester.

Note: This briefing is only concerned with first trimester abortions of established pregnancies (i.e. not emergency hormonal contraception which the High Court confirmed is not an abortifacient in R (on the application of Smeaton) v Secretary of State for Health [2002] 2 FLR 146). The BMA is using The Royal College of Obstetricians and Gynaecologists’ definition of the first trimester as “up to around 13 weeks”.

In particular, the requirement for a medical justification for an abortion carried out at 13 weeks or earlier is now unnecessary as evidence shows that the risks involved in first trimester abortion, particularly medical abortions, are less than the risks associated with carrying a pregnancy to term (see reference 1). In practice, few, if any, women will fail to meet the medical criteria in the first trimester. Access to first trimester abortion should therefore be available on an informed consent basis as with other medical procedures.

The need for two doctors to approve a termination of pregnancy 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.

Removing these two conditions from the legislation will remove the administrative burden created by the Act that, in reality, do not stop women seeking abortion, but potentially exposes them to delays, and consequently more costly and higher risk procedures.

The BMA therefore supports the revision of the Abortion Act 1967 so that, in the first trimester:
  • women are not required to meet medical criteria for abortions
  • the requirement for two doctors to confirm that the abortion meets the legal criteria is removed.
Health professionals with a conscientious objection to abortion should retain the right to opt out of providing abortion services, but should make their views known to patients and enable them to see another doctor without delay.

How would this work?
If the BMA’s proposals were incorporated into the legislation, the procedure would be as follows:
  • A pregnant woman who wishes to terminate her pregnancy in the first trimester will either go to her GP for a referral or self-refer to an abortion service provider.
  • The woman will be examined to confirm her gestation. She will be given information about the procedure, and the time to consider the various options available. She will be offered the option of counselling.
  • Once the woman is ready to proceed, and consent has been obtained, the abortion will be carried out.
Note: the BMA’s annual conference in 2005 voted overwhelmingly against a reduction in the 24-week time limit.

Background
In England, Scotland and Wales the Abortion Act 1967 (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.”

Currently a woman seeking a termination of pregnancy must find two doctors who believe she meets at least one of the four criteria outlined above. In reality, a woman who is seeking an abortion in the first trimester will generally satisfy the first provision since an early termination is less risky to her health than pregnancy and childbirth.

First trimester abortion in practice
In England, Wales and Scotland, the vast majority of abortions take place in the first trimester of pregnancy. In 2006, 89 per cent of abortions in England and Wales were carried out at 12 weeks or earlier (see reference 2), and 93 per cent of abortions in Scotland were carried out at 13 weeks or earlier (see reference 3).

Where a woman has made up her mind to seek an abortion and meets the legal criteria, it is better for the abortion to be carried out earlier in pregnancy rather than later, where this is an option. It is safer for women, resulting in a lower risk of complications (see reference 4), and is 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 (see reference 5).

Delays in accessing abortion services
Where women meet the legal criteria for abortion, and have decided to terminate their pregnancy, delays in accessing services should be kept to a minimum. Recommended standards from the Department of Health (see reference 6), Royal College of Obstetricians and Gynaecologists(see reference 7), and the Medical Foundation for AIDS and Sexual Health (MedFASH) (see reference 8) state that women should have access to abortion within three weeks of their referral. Despite this there is considerable evidence that women experience delays accessing abortion services (see references 9, 10, 11 and 12). There have been some moves to address this, with the Department of Health allocating money to primary care trusts (PCTs) that need to improve early access to abortion (see reference 13).

Removing the requirement for medical criteria for first trimester abortion
Women should be allowed to decide for themselves, on the basis of informed consent, whether to continue an unwanted pregnancy in the first trimester, rather than having to demonstrate that they meet 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), including Australia, Austria, Belgium, Canada, Denmark, France, Germany, Italy, Sweden and some parts of the USA (see reference 14).

Removing the requirement for two doctors
Under the legislation, two registered medical practitioners must be of the opinion that an abortion can be performed on one of the grounds in the Abortion Act (except in emergency situations). 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.

The BMA believes that the requirement for two doctors’ opinions should be removed for abortions within the first trimester.

Public support
There appears to be some support amongst the public for legal change. Ipsos MORI has conducted surveys that have broached this issue over the last decade. Most recently, in 2006, a MORI Ipsos MORI (see reference 15) survey conducted for BPAS (formerly known as the British Pregnancy Advisory Service) showed that:
  • 63 per cent of the 2,140 surveyed agreed that “If a woman wants an abortion, she should not have to continue with her pregnancy”; 18 pre cent disagreed; and
  • 59 per cent agreed that “Abortion should be made legally available for all who want it”; 27 per cent disagreed.
In March 2007, a poll conducted by research group GfK/NOP, commissioned by Abortion Rights and the Joseph Rowntree Reform Trust, showed that 77% of the 1,000 surveyed agreed with the statement “Do you think that women should or should not have the right to choose an abortion in the first three months of pregnancy”. Although the question is ambiguously phrased, the poll has been quoted in the media as supporting abortion “on request”.

If the medical criteria were removed, this would not prevent data being collected centrally about abortion provision.

References:
  1. 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.
  2. Department of Health. Abortion statistics. England and Wales, 2006. Statistical Bulletin 2007/01. London: DH, 2007.
  3. ISD Scotland. Scottish Health Statistics. Edinburgh: ISD Scotland, 2006. These percentages have remained constant over the last decade.
  4. Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. London: RCOG Press, 2004:23.
  5. Ibid:8.
  6. Department of Health. Effective Commissioning of Sexual Health and HIV Services A Sexual Health and HIV Commissioning Toolkit for Primary Care Trusts and Local Authorities. London: DH, 2003:27.
  7. Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. Op cit: 7.
  8. MedFASH commissioned by the Department of Health. Recommended standards for sexual health services. London: MedFASH, 2005:7.
  9. Lee E, Clements S, Ingham R and Stone N. A matter of choice? Explaining national variation in teenage abortion and motherhood. York: Joseph Rowntree Foundation, 2004:36.,
  10. All Party Parliamentary Pro-Choice & Sexual Health Group. NHS Abortion Services. London: Voice for Choice, 2004: 6-7.,
  11. Dorries N. House of Commons Hansard. 18 Jan 2007: col 925.,
  12. Pro+choice forum. Late Abortion: A Review of the Evidence. Pro+choice forum, 2004. Available at www.prochoiceforum.org.uk/pdf/PCF_late_abortion08.pdf (accessed on 28 Jan 2007).
  13. Department of Health. Resource and cash limit adjustment in respect of improvements in early access to abortion services. Gateway reference 5567, 29 Sept 2005.
  14. United Nations Department of Economic and Social Affairs, Population Division. Abortion Policies: A Global Review. United Nations publication, 2003.
  15. Attitudes to Abortion, 28 Nov 2006. Available at www.ipsos-mori.com/polls/2006/bpas.shtml (accessed on 26 Jan 2007).
For further information, please contact the Parliamentary Unit:
Email: parliamentaryunit@bma.org.uk

© British Medical Association 2008

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