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Tuesday 23 September 2008, 9.00-9.30pm
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CASE NOTES Programme no. 9 - Abortion







Hello. For the last programme in the current series of Case Notes, we have decided to tackle a sensitive issue - abortion. We won't be debating the moral, ethical or legal dilemmas that so often polarise opinion on this controversial subject - rather we'll be looking at the practicalities of a procedure that nearly a thousand women undergo every week day throughout England, Scotland and Wales. Abortion is still illegal in Northern Ireland except in exceptional circumstances.

So, how are pregnancies terminated in the 21st Century? What is it like for women involved? And what about the doctors and nurses - does their duty of care override their personal beliefs?

They just didn't want to be involved, they didn't give me any information. So actually I left my GP and the consultant gynaecologist at the hospital knowing nothing, other than that I was pregnant, a sense of the fact they didn't want to be involved.

And why are more and more women having abortions despite better access to modern contraceptive methods, including the morning after pill?

It was sort of a spontaneous night and I'd literally just finished my period and I thought that I couldn't get pregnant. Clearly that's a myth.

Under the terms of the 1967 Abortion Act - which legalised abortion - a woman can have an termination if two doctors agree that certain criteria have been met. Around 1 in 30 abortions is done for serious medical problems, like foetal abnormalities, with the remaining 97% being done under Clause C. This allows for abortion as long as the woman is no more than 24 weeks pregnant, and that continuing the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the woman. A clause that essentially allows for safe abortion on demand. But things used to be very different.

Lesley Hall is senior archivist at the Wellcome Library.

Because going back for a very long period there were a lot of things like herbal and folk remedies for women who wanted to terminate their pregnancies, a lot of these were in fact very dangerous and likely to be extremely toxic and they might well kill the woman as well. But nonetheless there was this kind of folk knowledge which possibly tended to get lost a bit when people started to move into towns because that's when you get people selling abortion pills, which don't actually work, which were an absolute scam and a rip off but they - they don't actually call them abortion pills, they call them female pills. And they say things like removes all obstructions and soothing to the female mind but you realise that the subtext is that they're to terminate pregnancy and they do quite often have the name that suggest they're using some of these old - older remedies but of course they don't. For example, parsley - just brewing up a tea of parsley isn't going to make much difference but if you extract the essential oil that's actually quite toxic and does have effects on the uterus which could cause an abortion. And also other substances like ergot, which is a fungus which grows on rye, which are known to cause miscarriage but again they are all substances which have a very deleterious effect on the whole woman, they're not just kind of magic bullets that will terminate the pregnancy, they will have a very serious effect.

And then you have various means by which people can operate and there is what might be called the Harley Street racket in abortions from at least the late 19th Century where there were known to be a group of doctors in fairly elite practice who were doing abortions for fairly substantial sums of money.

And then of course you also had the back street abortionists like Vera Drake in the movie, it was a person who didn't necessarily have any formal medical training but who had learnt how to do this operation of opening the cervix and therefore provoking the uterus to expel its contents either by using slippery elm bark, which is this tree bark that once it gets moist it expands, so if they put a little plug of that in the cervix it would expand and probably cause an abortion. And then also there's the whole kind of syringe and soapy water thing, which was what you saw with Vera Drake, that she had the carbolic soap and she had the syringe and the tube which required a certain amount of dexterity but some of these women were very skilled. It comes up in the court cases quite often, when something did go wrong and a woman died or was very ill and had to be taken to hospital. The woman was known in the community and it was known that she had done this operation hundreds, sometimes thousands, of times without any accident, there was a level of skill there. Women were often very reluctant, even when the police came to their bedside in the hospital, to say - and they say who did this to you, who did this to you - and they wouldn't say.

When the Abortion Act first came into force just over 50,000 pregnancies were aborted in England and Wales in the following year. Today that figure is closer to 200,000. But who are these women? Ann Furedi is the Chief Executive of the British Pregnancy Advisory Service - one of two principal charities who perform the lion's share of those abortions.

You know they are absolutely normal women, they're exactly the kind of woman who lives next door to you, who you meet at the school gates, younger teenage girls but they're the ones that get talked about a lot and in fact the majority of women who have abortions in this country are in their twenties but they're fit, fertile, completely normal women and many of them would never ever have thought that they would have an abortion in their life.

I found out this week that I was pregnant, unexpectedly and I gather that I must be very, very early stages because I really started feeling nauseas and I thought it was a stomach bug.

Usually when we're having sex we don't want to get pregnant as a result of it. We expect to be able to control our fertility by using methods of birth control. But all of them have a failure rate and when they fail or when we fail to use them correctly then I think that many, many women today expect to be able to do something about it and abortion is the thing that they can use as a back up to their birth control.

But there is an intermediate step and that's emergency contraception which can be used for up to five days if you use the IUD - intrauterine device - up to 72 hours if you use the pill, I would have thought that most women would have known about that by now, is that not the case?

All of us have a bit of a tendency to hope for the best and one of the problems with emergency contraception I think in this country is that we've never really popularised the idea of women keeping it at home, getting it in advance of their need to use it. We expect women to go and get it from the pharmacy or get a prescription from the doctor only when they've had unprotected sex and that seems to me utterly crazy - you don't wait until you have a headache before you go and get your headache medication, if you know you're prone to it you keep it at home. And I think that if we could popularise that more then more women would be inclined to use it because they'd have it to hand and they wouldn't have to make a special trip.

John Spencer is a consultant gynaecologist with 20 years experience in the NHS, and now works for Marie Stopes International, who along with the BPAS do most of the private and NHS abortions in the UK.

There have been some startling changes with the provision of termination of pregnancy. The National Health Service used to have terminations of pregnancy on most gynaecology lists and as a gynaecologist one went into the business without thinking that this would be a part of the daily duty but increasingly as the attitudes on both sides of the argument, if you like, have become more prominent, i.e. both for and against, doctors have been allowed to express their conscientious objection and that includes gynaecologists. So increasingly trainees in gynaecology have been allowed to declare that they do not wish to participate in the offering of this provision. There remains an obligation that all doctors are obliged to deal with any of the consequences, in terms of medical complications or emergencies.

I think that their duty is to refer the woman, the girl, on to a colleague who does feel comfortable with dealing with it. I don't think we should make it more difficult in any way for doctors to object to being involved, I think it's wrong to force doctors to act against their conscience and I can't possibly believe that they would give good information to the women involved. But I do think that they should refer on very quickly and I would like to see GP practices being very open and transparent about the views of their doctors, it seems to me that that would be helpful to the doctors and it would also be helpful to the women. I think the biggest problem is where doctors may be don't have a conscientious objection but feel that they should interpret the law in an unnecessarily arduous manner, so it's the doctor who says to the woman well I see no grounds for you to have this abortion, you're clearly a very good mother, one more won't make any difference, as a doctor that we heard about - said recently to a client of ours.

Well that's applying the strict letter of the law, I suppose, and what we're saying is that we need to be more candid that actually - or you can drive a coach and horses through those criteria.

We do and what we have at the moment is a law that reflected the views of society in 1968 and society has moved on immensely and what we need is a law that now reflects that and that's what we're hoping that we will get out of the political discussion in Parliament that looks as though it will now take place in the autumn.

There is nothing worse than going for a procedure that nobody wants to do.

In a hospital where they don't do many.

And where - as I found myself in the situation for many years being quite sympathetic towards this business but - and without implying any criticism - the nursing staff and other staff within the hospital were not necessarily so sympathetic. So it became increasingly difficult to provide a service and the surgical service began to disappear. But I think you're right in terms of now the majority of procedures in the country are provided by specialist units and the quality of care is excellent.

John Spencer.

Counselling - which should include an explanation of all the options open to women with an unwanted pregnancy - is offered to every woman seen by Marie Stopes and BPAS, and around 1 in 10 decides not to go through with it.

Of the remainder who do, nearly all will less than 12 weeks pregnant and around three quarters of them will have a surgical abortion which John Spencer described to me.

The large majority will have what's known as a suction termination, a variance of that would be described as a manual vacuum aspiration, for example. But it is - it's a procedure that requires a degree of analgesia, the passage of a cannula into the uterus to evacuate the contents.

So it doesn't have to be done under a general anaesthetic but you're using some form of pain relief.

Our general anaesthetic rates are no more than 20-25%. Conscious sedation is the most popular assistance but a fair number of women can manage this with very minimal analgesia, some with none at all. And certainly if the woman's been pregnant before and had children then it is certainly something that she could consider not requiring any systemic pain relief.

So then a cannula - a hollow tube - is passed through the cervix and into the womb and that's then used to evacuate the contents, the early developing pregnancy, which is how big in somebody who's 8-10 weeks?

Eight to ten weeks, we're probably talking three to four centimetres in length but very, very fragile, I mean it is only soft tissue, very easily evacuated through small cannulas. And for example at eight or nine weeks one only needs a cannula of five millimetres in diameter.

And the complications - surgical complications - obviously you're going to have infection and bleeding, how much of a problem are they these days?

They're a small problem, we tend to run - well less than 1%. The most common symptom is that there is still bleeding and that can be a combination of either some small fragments of tissue remaining, what we call "retained products", with or without some infection. There can be infection of the lining of the womb or endometritis on its own but commonly the two go together. And treated with antibiotics and possibly tablets and rarely a second procedure to clear out any remaining tissue.

John Spencer from Marie Stopes International. Paula McGrath went to one of the Marie Stopes clinics, where she met Susie who had just had a surgical abortion.

I've been pregnant before and I've got a little son and I just felt that I wasn't ready to have another baby yet, I wanted to give him as much as I could and I just thought if I'm going to have another baby before he's even two and I felt that I wouldn't be able to cope with that.

So what did you do - did you go and see your own doctor?

No, I didn't. I spoke to my husband and I literally made the decision within 24 hours because I knew that if I harped then I wouldn't do it. And I would start getting too attached. So it was kind of like it was do it or not and so I just said I'm just going to do it, I didn't go through my doctor. I phoned this clinic immediately.

And what sort of experience has that been for you, what did you have to do?

It was easy, you just phone and within 24 hours, less than 24 hours, I had an appointment I was quite surprised actually, I didn't think it would so quick. But I was relieved because I just wanted to get it over and done with as soon as possible. Came in this morning and I didn't have any anaesthetic because I wasn't very far in my pregnancy, so I just had a surgical procedure in which - they call this the suction and it literally is less than five minutes. A bit uncomfortable, I was crying the whole way through because I was - obviously all those thoughts going through my head - am I doing the right thing, am I going to regret it? But it was quick, very, very quick, I didn't have any painkillers, I didn't need any painkillers, I don't feel sore now.

And you said that you had the suction procedure - what other kind of options were you faced with and why did you chose the one that you did?

When I read about them there was the - you can take a tablet - but I didn't like the idea of prolonging it because you take a series of tablets over 48 hours and you're kind of dealing with sort of the signs of a miscarriage and that just didn't appeal because then it's so much more real. For me this was literally wham bam thank you mam, it's over, it's done and you don't have to think about it again. And then you just get maybe a period, you know, as normal. And then the other way you can also have general anaesthetic and I didn't want general anaesthetic because I didn't want to be knocked out and then have to stay here longer than needed, I wanted it as quick and painless as possible.

And if someone was thinking about going to have a termination, like you've had today, what would you say to them?

I'd say make the decision fast, don't harp on it because if you harp on it then you're just going to regret it for too long and do it as fast as possible, as early into the pregnancy as possible, don't leave it.

The earlier a termination is done the easier it is technically to do - indeed women who present before the ninth week of pregnancy needn't have any surgical intervention at all. They can be offered a medical abortion induced by drugs. Mifeprostone - otherwise known as RU486 - was developed in France 20 years ago and is now used in around a third of all abortions. Kate Guthrie is consultant gynaecologist in Hull and East Yorkshire where she splits her time between hospital and the community. I asked her how this so called "abortion pill" actually works?

It's an anti-progesterone which stops the pregnancy from continuing. That's the one that actually stops the pregnancy.

So effectively it's inducing a miscarriage?

Yes, women quite often refer to it as the miscarrying process, which sounds a bit better than the aborting process and the process is exactly the same. And that's why medical termination is very attractive because it is very similar to a spontaneous miscarriage which everybody understands even if they haven't undergone themselves.

Now that's the first part of the process. Is that enough in some women to induce a miscarriage?

No, when this whole thing was first invented the hope was that this pill would be enough but in fact something like 60% of women don't go on to abort within the next few days, they abort gradually over the next few weeks possibly and end up having to come back into hospital for an operation. So after 36-48 hours - and current research is saying in fact that time interval could be brought down - the woman comes back to the hospital, it has to be back to the hospital because of the law as it stands just now, and takes a further set of tablets which cause the womb to contract and expel the pregnancy and make the actual physical process happen.

What would the woman herself notice?

Usually nothing happens between the two sets of pills. But occasionally you can get a feeling of cramps or bleeding like a period's due and if the pregnancy is probably going to miscarry anyway it could well miscarry between the two visits for the pills. So we give women information on this and tell them where to ring if anything happens or they want any advice. And some women may say at the second visit oh I had a bit of bleeding and some pain, in which case we would organise a scan because in fact those women may or may not have miscarried at home. The pregnancy's very early and it's very difficult to tell sometimes if there's a miscarriage or just bleeding.

What happens to those who've been given the second dose - do they then go back home?

It varies from unit to unit. Where I am we ask the ladies to come back quite early in the morning and if you like they're booked in for the day and [indistinct word] tummy pains and bleeding and miscarry the pregnancy while in the unit. If not a lot happens to begin with then they're given a second set of tablets to maximise the chance of the miscarrying happen while they're actually in the unit.

But in some parts of the country the women are given the pill and then they go straight home.

Yeah in some parts of the country there are no rooms to stay, go home and I think in other parts of the country women are given the choice. I would actually like to see a service where women are given the choice because some women absolutely require and want to be within a nursing environment whereas other women at a very early stage in a very safe process would rather go home and be with friends and family. We took part in research run by Aberdeen where I think four or five centres gave questionnaires to women to say do you want to stay or do you want to go home and what we find, and what we find in the States as well, is that women who have little knowledge of what's happening next quite naturally want to stay, women who have more information or friends who have been through the procedure or where there's a local culture of going home say I'm very happy to go home and I'll give you a ring if I have any problems.

Can you ever envisage changes to the law regarding termination that means perhaps we could use the abortion pill as an extension of the morning after pill?

The UK was way ahead of the rest of the world in legalising abortions and saving women's lives but other parts of the world have had more recent legislation. I think actually they have better legislation than we have now because women do get the hoice of not having to come into a central unit, like a hospital. Travelling is difficult for women, particularly with young children or they're allowed to take some of the tablets at home. And I certainly would like to see the UK law progress in that direction.

And practically that would mean what sort of changes - are you suggesting that the - perhaps only one doctor would have to sign the paperwork, so maybe a GP could do it in his or her surgery?

Well that's a different issue, I mean that's just like - that's paperwork but I certainly think that if you're looking at a procedure why drag women all over the country to have a procedure which they can have locally? Now if they're going to have it locally it has to be to exactly the same standard as they would if they went to a centre. It doesn't require changing the law but the Secretary of State for Health could open up the number of places where this procedure was able to be undertaken, which for medical termination is swallowing the pill. At the moment the law is that that pill and the subsequent tablets can only be taken either in an NHS hospital or some place licensed which is one of the charity providers. The Secretary of State would have to open that up to other classes of place which we assume would be perhaps family planning clinics or large general practices.

What would you say to someone that might argue that by making it easier to access abortion, particularly medical abortion, that you're actually encouraging more women to come forward for termination?

It's never been shown that to research because if a place has a very poor termination service has a better service initially the abortion rate will go up because you're giving women access to something they never had before yet women don't like having terminations, I don't believe anybody sets out to say ooh we'll have a termination. I do have a real problem with men sometimes, I think men sometimes think oh well there's a fallback position - I know this because of local research - the fallback position is never mind you can have the morning after pill or an abortion and for women it just isn't like that. I'm acutely aware that the abortion rate in the UK is gradually rising and I'm acutely aware that the abortion rate in particularly young women who are the heaviest users of abortion is rising. But I really do not believe that this will become within our culture the equivalent of well I'm not going to bother, I can go and have an abortion because it's a fairly traumatic thing to have.

And while recent advances may have reduced the impact physically, abortion can still exact a high toll psychologically. John Spencer again.

The decision to terminate an unplanned pregnancy is evidently very difficult for the majority of clients. There is a situation that some people call post abortion syndrome but in all probability this is a variant of post traumatic stress syndrome triggered by the very difficult experience that the woman has had in making the decision to go through with a termination of the unplanned pregnancy.

What sort of symptoms do they complain of?

Difficulty of sleeping, they have flashbacks, nightmares and then finally their behaviour is often affected in a way that tries to avoid any reminder of the situation they've been through.

And in your experience what proportion of women could expect to have problems like that?

I probably can't speak personally from experience but my understanding from our organisation and from looking at the literature some report figures up to one in five, personally I should think that's a bit high and I wouldn't be surprised that up to one in five women have some degree of difficulty coming to terms with this kind of event, not dissimilar to the loss of a wanted pregnancy, with a stillbirth I would think.

Jenny had an abortion nearly 30 years ago, and didn't struggle with it emotionally as much as some of her friends thought she might.

I didn't think I could be pregnant, I'd been married, tried for babies for a couple of years, nothing had happened, so I just said to myself okay you can't have babies. And when my marriage broke up I had an ill advised relationship with somebody for a few months. I suppose I did start putting on weight and getting rather fat and all this but I just didn't think about pregnancy as an option really. Then I bumped into a friend that I hadn't seen for some months and the friend's first reaction was you know you look very pregnant.

So you don't have regrets, because you often hear, you know, the sort of stereotypical woman who's been through a termination of pregnancy is that when she comes out at the other end it's something that is a difficult part of her life that a lot of women regret it looking back?

Well this is something people tell you, people who haven't had abortions and I must say I'm very careful about who I talk to about it because people warn you - people give you all sorts of threats and terrifying scenarios. One of my closest friends said to me before I had it done, she said - You will probably suffer from severe depression on the anniversary of what would have been the birth for the rest of your life. And those kinds of threats are frightening because you - actually you don't know what's going to happen to you. But I never did, I have never suffered from that because I think I felt that it was the right decision for me.

Jenny talking to me about her thoughts nearly 30 years after she had an abortion.

We heard earlier that gynaecologist, Kate Guthrie, doesn't believe that easier access to abortion is encouraging more women to come forward and ask for one. So why is our abortion rate so high, and continuing to rise. Ann Furedi from the BPAS.

One of the issues in Britain is that perhaps abortion over recent years has become seen as a more acceptable option. And certainly more of an acceptable thing for a woman to do than to have a child that she doesn't want and doesn't feel that she can care for. But one of the things that we have in this country that I think does set us out is that on the one hand we have a quite liberal attitude to sex, young people don't expect to wait until they're married or even in a very serious relationship before they start experimenting with sex, but at the same time we're not very good at really promoting their need to use contraception very well. And what you find in many of the Scandinavian countries is that they are incredibly good at encouraging young girls to start using the contraceptive pill, even before they start having sex, and that's a really big difference. In Britain there's still a bit of a sense that you shouldn't be going to your doctor to ask about contraception until you are in a stable, serious relationship.

But over the last five years we've seen a concerted effort to try and improve access, to improve awareness, make the emergency contraception more available but actually during that time it doesn't seem to have had any impact, in fact if anything the rate has crept up slightly.

That's absolutely true and I think it illustrates really well the fact that contraception is difficult for people to use. Somebody a lot more articulate than me who works in family planning said that sex is hot and contraception is cold and I think a lot of young people may be in denial that they're going to start having sex because they still think it's a bit of a wrong thing for them to do. And even when they do they maybe thinking well it's never going to happen again.

Just the sort of the last thing is that a woman mustn't think that this is really easy and simple and you can just walk in and it's done and gone in five minutes. This is not a method of birth control. So women still must be aware that they need to use contraception, and myself included, one stupid night, please don't think that, it's much harder than that.


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