In April 2019, the National Institute for Health & Care Excellence published their new draft guidance on abortion. Here is our consultation response to their proposals.
Life welcomes the opportunity to respond to the NICE draft guidance for termination of pregnancy.
Life is a charity which offers housing, support and counselling to thousands of women facing unplanned or crisis pregnancies each year.
This submission draws on Life’s 50 year experience in developing a person-centred counselling service. Our service aims to create a safe space for women to explore and consider their emotions, free from external pressures.
It is our concern that the NICE guidance, in its present form, will result in women being rushed through the abortion process; something patients have expressed concern about in recent years.
We have identified several specific issues with the draft guidance which we believe need correcting:
- The lack of independent counselling, prior to termination.
- The move towards “telemed” consultations which would be ineffective at identifying vulnerable patients and those with complex comorbidities.
- The trivialisation of the impact abortion can have on mental health.
- The removal of consideration periods prior to termination, which provide women with time to consider all options available to her.
- Emphasis on cost cutting.
- Insistence on cutting waiting times in order to save money, rather than it being in the patient’s best interests.
- Emphasis on economising in order for resources to be channelled back into new referrals, feeding a conveyor-belt culture.
- Promoting medical over surgical abortions on the basis of cost-cutting, rather than the needs of the woman.
- Removing doctor involvement.
- Removing doctor involvement in the abortion procedure whilst simultaneously encouraging the patient to take powerful drugs in a non-clinical setting.
- Reducing care.
- Not providing routine follow-up appointments for women who have aborted at home, despite risks of incomplete abortions or abnormal bleeding.
- Essential medical training.
- Increased integration of abortion training and practical experience into training for health professionals, making conscientious objection more difficult for those who are morally opposed to being involved in the procedure.
We believe that the stated aim of the draft guidance, to “improve the organisation of services to make it easier for women to access a termination” (p.1), is a flawed starting point. This objective streamlines a procedural pathway geared towards one outcome only: abortion.
Rather, if the medical profession truly seeks to improve patient care in the event of an unplanned pregnancy, then it is crucial to take the patient’s potentially complex circumstances as its starting point, not defining the outcome prematurely.
No independent counselling prior to abortion.
It is discouraging that NICE does not intend to prioritise counselling prior to a woman’s decision to abort and actually intends to curtail a woman’s access to emotional support before making this life-changing decision.
By encouraging “self-referrals” directly to abortion providers (p. 25), thereby circumventing consultations with a GP, the patient loses an opportunity to talk through their options with an impartial professional and potentially receive emotional support. While private providers such as BPAS or Marie Stopes International (MSI) may claim to offer similar services in relation to counselling, they cannot be impartial due to their financial incentive of the woman choosing an abortion.
This has been clearly demonstrated in the case of Marie Stopes, where, in 2017, the Care Quality Commission (CQC) accused Marie Stopes of paying bonuses to staff who encourage women to have abortions. This was corroborated by MSI staff at Maidstone who told CQC inspectors that the clinic was like a “cattle market” and described a “very target-driven culture”. Reports of abortions being signed off by Marie Stopes after telephone discussions as short as 22 seconds demonstrate that self-referrals simply rush women through the abortion process. This is obviously not patient-centred practice or in the patient’s best interests.
Independent counselling remains a priority for women across the UK. 2017 ComRes polling showed that 93% of women want independent abortion counselling introduced. The advice in this guidance therefore goes against what the majority of women want with respect to their own care, placing an emphasis instead on speed and cost-saving.
Missing vulnerable patients, safeguarding & key medical history.
By removing GP consultations and promoting self-referrals and “telemed” consultations (p. 5), opportunities to identify vulnerable patients will be missed, as well as key medical history which may be crucial for patient safety.
It is unlikely that a “telemed” consultation by an abortion provider, potentially less than a minute long, would be able to identify a woman who is suffering from domestic violence, or a young person being pressured into an abortion by relatives.
This is particularly relevant in light of a 2014 study of London abortion clinics (1) which showed there was a six times higher rate of intimate partner violence in women undergoing abortion compared with women receiving antenatal care (2).
In 2016, the CQC identified that MSI staff were not “being appropriately trained to explore issues such as female genital mutilation and child sexual exploitation”.
From a medical perspective, phone consultations for women with complex comorbidities would also be unsuitable and could result in key information being missed.
Similarly, if a private abortion provider has not identified a woman as having an active or latent STI over the phone, proceeding with an abortion in this scenario could cause long-lasting and detrimental consequences to the patient’s reproductive health.
Trivialisation of mental health.
In terms of counselling, it is highly problematic that the NICE guidance directs medical professionals to tell women that “having a termination of pregnancy does not increase their risk of long-term health problems…such as… mental health issues” (p. 7), without citing an evidence base for this assertion.
It is possible that NICE may be relying on the 2011 review by the Academy of Medical Royal Colleges, Induced Abortion & Mental Health, to make this claim. This study noted that “the rates of mental health problems for women with an unwanted pregnancy were the same whether they had an abortion or gave birth” (3).
The report did concede, however, that “the most reliable predictor of post-abortion mental health problems was having a history of mental health problems before the abortion”.
This is significant given that the Adult Psychiatric Morbidity Survey (the only national source of information on rates of treated and untreated mental illness) has stated that as many as one in five women in the UK have a common mental disorder (CMD), with rates having steadily increased in women since 2000.
Setting aside the likelihood that women with mental health conditions may be an overrepresented group amongst the 200,000 women who have abortions in the UK every year (as those with mental health problems may feel less able to continue with an unplanned pregnancy than those without) this would still amount to a considerable number who could potentially be affected by post-abortion mental health problems.
Conservatively applying the ‘one in five’ figure to 200,000 women still leaves 40,000 women across the UK every year at risk of developing potentially serious mental health problems following an abortion.
This estimate corresponds with the post abortion clients that use Life’s services each year, coming to us to help them process the intensity of their emotional and psychological issues
Thus, telling all women, irrespective of their medical history, that there are no long-term psychological ramifications to having an abortion is imprudent at best and reckless at worst. This is particularly true in situations where a pregnancy may be “wanted” but the patient feels they have “no choice” but to abort, perhaps due to financial reasons or a difficult relationship.
The conclusion also discounts the robust and comprehensive findings from Prof. David Fergusson, who, despite setting out to prove that abortion did not increase a woman’s risk of mental health problems, drew the conclusion from 30 years’ worth of data that abortion was an independent “risk factor for the onset of mental illness” (4). His own study found 42% of the women in the post-abortive cohort had experienced major depression during the previous four years, twice the rate of those who had never been pregnant and 35% higher than those who had continued with their pregnancies.
In 2016, researchers attempted to replicate Fergusson’s findings in a well controlled study of over 8,000 women. Likewise, they also found a 30% elevated risk of depression and a 25% elevated risk of anxiety in women who had abortions (5).
Removal of waiting times.
It is also concerning that the draft guidance directs professionals not to give “compulsory time for reflection before the termination of pregnancy” (p. 5).
This advice contributes to the to the tone of the document which seemingly places speed and immediacy above concern for the patients well-being.
The removal of waiting times also proves to be out of step with what the majority of British women want, with 78% of women in the UK expressing their support for a five-day consideration period before abortion in one 2017 poll.
Reflection periods ensure that a women considering an abortion has had enough time to consider all of the options available to her.
Only post-abortion counselling offered.
It is regrettable that NICE only directs health professionals to suggest the offer of counselling post-abortion (p. 21).
If potential emotional repercussions are a reasonable plausibility for many women, it seems logical that counselling should be offered prior to undergoing a termination, as well as after. This would also provide further opportunities for mental health screening to identify patients at risk of psychological problems post-abortion.
One client shared her experience of how she wished she had been listened to prior to her abortion and how she struggled with the consequences for many years afterwards:
“Society doesn’t allow you to feel guilty or grieve for my lost babies, because when you do try to say to your partner or friend or relative how you are feeling all you get back is ‘it was your decision’ – no it was never my decision, all I kept hearing was ‘you are doing the right thing’, no one ever asked me how I was really feeling or told me how I would be totally consumed by the terrible grief and the loss of part of me. Over the years I have just bottled it all up, trying not to face the pain, speaking about it now is lifting an all-consuming weight from me”.
This testimony goes to show that for some women, years of suffering could be avoided if they are given adequate space before having an abortion to explore their feelings and determine whether this is something they really want, or is it something they feel they are expected do.
It would appear that cost-cutting is one of the greatest motivating factors behind streamlining the abortion process.
Reduction in waiting times.
An alarming statement is made on page 28 of the guidance: “Even small reductions in waiting times would result in large cost savings. A reduction of 1 day in the average waiting time would save the NHS £1.6 million per year” (p. 28).
One day more for a woman about to undergo a termination could make all the difference to her decision. In a crisis pregnancy scenario, time is a precious resource. It is integral to the self-actualising process that a person is “allowed” to process their thoughts in their own world.
To calculate the cost of those 24 hours is cold and insensitive. Rushing a woman through the abortion process is dehumanising to the woman and trivialising the seriousness of her decision.
It also appears that one of the goals of cost-cutting is to redirect those resources into obtaining new referrals. This is mentioned on page 29 of the guidance: “…recommendations on expulsion at home and remote follow-up will minimise the number of appointments needed, so there will be greater resources available for new referrals” (p. 29).
New referrals for new referrals sake is not in the best interest of women but fuels the conveyor belt culture amongst private abortion providers, highlighted by the Care Quality Commission in recent years.
Medical over surgical abortions.
The draft guidance identifies instructs medical professionals to “provide information about the benefits and risks of medical and surgical termination of pregnancy” and to do so “without being directive, so that women can make their own choice” (p. 7).
That being said, the guidance later emphasises that “substantial cost savings can be achieved if women present earlier for termination of pregnancy. Most of this saving comes from women having a medical rather than a surgical termination” (p. 26).
If hastening the abortion process de facto results in an increase in medical terminations, which benefits the NHS financially, it is hard to see that women’s “choice” is being respected as claimed.
It must also be noted that a medical abortion can be more distressing for the patient who may have to “see the pregnancy as it passes” (p. 8).
Removing doctor involvement & reducing patient care
Removing doctor involvement.
The NICE guidance suggests “where possible, [to] remove doctor involvement with abortion procedures, replacing them with nurses and midwives” (p. 5).
This emphasis on the withdrawal of doctor involvement coincides with encouraging patients to take powerful drugs such as mifepristone and misoprostol in a non-clinical setting, such as their own home (p. 5).
If the objective of NICE is to always prioritise patient care and safety, it is difficult to envisage how these two recommendations can co-exist.
Again, it seems as if cost-cutting is the motivating factor behind this recommendation: “expanding the role of these [nurses and midwives] should increase the number of appointments available, enable women to present earlier and may also contribute to cost savings from earlier terminations” (p. 29).
On page 9, medical professionals are advised “not [to] provide routine follow-up appointments for women who have expelled the fetus at home or another location other than an abortion clinic or hospital” (p. 9).
Again, this recommendation makes it difficult to argue that patient safety is a priority in the new guidance.
Without routine follow-up appointments after a medical abortion, complications such as an incomplete abortion or abnormal bleeding may be missed.
If follow-up appointments are routine for women who have given birth, any less supervision for women who have had to deliver a fetus at home following an abortion, is simply a reduction in standards of care.
A final key concern is the objective to increase the integration of abortion training for medical and midwifery students (p. 5).
Although NICE recognises the right to conscientiously object to abortion (“ensure all trainees have the training, unless they opt out due to a conscientious objection” p. 5.), positioning the training as “essential” (p. 27) puts an undue burden on students who do morally object to what is undeniably a controversial procedure.
It would seem that NICE’s recommendation is in response to the decreasing number of doctors being prepared to perform abortions.
A 2017 Guardian article highlighted that “at 19 weeks there are just four hospitals offering medical terminations across the whole of England and Wales, and three offering surgical procedures. From 21 weeks, only Imperial College Healthcare NHS trust and King’s College Hospital NHS foundation trust, both in London, have one doctor able to undertake late procedures. At 15 weeks’ pregnancy, 18 hospitals across England and Wales can provide a medical abortion, 11 a surgical one.”
Prof. Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists, also told the Guardian: “when my generation goes, there will be very few people who have any experience. Less than a handful of consultants in England are doing late surgical abortions.”
By NICE creating a culture which makes conscientious objection more difficult to assert, the right is being respected in name only.
When taken as a whole, the recommendations in the NICE draft guidance on abortion provision create conditions for women to be rushed through the abortion process.
Throughout the guidance it appears that speed and cost-cutting take paramount over patient safety and acting in a woman’s best interest.
The CQC has in recent years have voiced concerns about the conveyor belt culture present amongst some private abortion providers and how this jeopardised women’s health.
Improve procedural pathways for patients wishing to explore alternatives to termination.
So far, very little emphasis is placed on alternative choices to abortion and what they might look like for the patient.
It would be beneficial for patients to know they had several realistic options available to them, in many cases this may alleviate the anxiety that they have “no other choice” than abortion.
Procedural pathways for patients wishing to explore alternatives to termination could be developed by medical professionals and NHS trusts providing patients with information about charities who would support them through their pregnancies, both practically and financially.
Analysis of why women have abortions to inform practice and support offered.
NICE guidelines should address the reasons women seek out abortion services in such high numbers in this country. This is often because of: vulnerability, isolation, lack of financial or emotional support, or pressure from a partner.
Rushing women through abortion process does nothing to address the problems these women already face and would only later compound these issues if coupled with post-abortion regret.
Increase funding available for independent counselling.
If 93% of women want independent abortion counselling introduced, this has to be a key priority in the procedural pathway, prior to termination.
It would be more appropriate for NHS savings to be redirected towards pre-abortion counselling in order to offer the best care to each patient facing an unplanned pregnancy.
More research into mental health risks associated with abortion in the UK.
The need for research becomes even more pressing in light of the fact that many abortions carried out in England and Wales are not properly recorded on women’s health records.
Private abortion providers such as BPAS and Marie Stopes International, who perform over two thirds of the UK’s NHS abortions, are not required to routinely record patients’ NHS numbers on HSA4 abortion forms. This means that outcomes of abortions and possible side effects (both physical and psychological) cannot be easily tracked in England as there is no record of them taking place on a woman’s medical history, despite the importance that such outcomes would have for research on women’s health.
This reality continues despite the Government’s pledge, under the Health & Social Care (Safe and Quality) Act 2015, to monitor all patient healthcare and outcomes from procedures commissioned or carried out by the NHS, through the use of a consistent patient identifier (i.e. the NHS number).
The inability for much of the UK to conduct accurate longitudinal research into the effects of abortion puts England, in particular, behind the rest of Europe.
Women are entitled to be made aware of all the associated risks of abortion in order to make an informed choice as to whether to go ahead with the procedure.
Health professionals cannot provide all the relevant information if research is not being funded, nor can be carried out in this area.
(1) Wokoma TT, Jampala M, Bexhell H, Guthrie K & Lindow S (2014) A comparative study of the prevalence of domestic violence in women requesting a termination of pregnancy and those attending an antenatal clinic. BJOG 121:627-633.
(2) The meta-analysis of 74 studies regarding the associations between abortion and domestic violence carried out by King’s College London and published in PLOS Medicine in February 2014 provides an extensive scientific review of this topic.
(3) There were also serious limitations to the findings. The authors admit that “many of the studies included in the review failed to take into account important factors such as previous mental health problems, whether the pregnancy was wanted or not, and intimate partner violence and abuse”.
(4) Fergusson DM, Horwood LJ & Ridder EM (2006) Abortion in young women and subsequent mental health. Journal of Child Psychology and Psychiatry 47(1):16-24.
(5) Sullins DP (2016) Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States. SAGE Open Med 4:1-11.