UK – fetal anomaly, surgical abortion and premature birth

Surgical termination of pregnancy for fetal anomaly: what role can an independent abortion service provider play?

by Helen Callaby, Jane Fisher, Patricia A Lohr

Journal of Obstetrics & Gynaecology April 2019;39(6):799-804   (Not open access)

DOI: 10.1080/01443615.2019.1568973

Abstract

Most hospitals in Great Britain only offer a medical termination of pregnancy for a fetal anomaly (TOPFA) in the second trimester. We describe the safety and acceptability of a surgical TOPFA service delivered by an independent-sector abortion provider. Non-identifiable data for women undergoing TOPFA at British Pregnancy Advisory Service from 1 January 2015 to 31 March 2016 was extracted from existing databases. Anonymous feedback was obtained using a questionnaire. Women (n=389) were treated along a specialised care pathway within routine abortion lists. The anomalies were chromosomal (64.0%), structural (30.8%), suspected chromosomal and/or structural or unknown (5.1%). The termination method was vacuum aspiration (41.9%) or dilation and evacuation (58.1%). No complications were reported. Feedback (173 women, 122 partners) indicated care was sensitive (99.6%), supportive (100.0%), knowledgeable (99.2%), and helpful (100.0%). Most (92.1%) reported the right amount of partner involvement. All of the respondents were likely/very likely to recommend the service. A cross-sector approach safely and satisfactorily increases the choice of TOPFA methods.

What is already known on this subject? A surgical abortion in the first and second trimesters has been demonstrated to be safe and acceptable, if not preferable, to a medical induction for most women, including those seeking a termination of pregnancy for a fetal anomaly (TOPFA). However, most hospitals in Britain only offer a medical TOPFA in the second trimester, often due to a lack of skills to provide a surgical alternative. The lack of choice of method has a negative impact on women’s experiences of TOPFA care. Independent sector abortion clinics provide the majority of surgical abortions in the second trimester in Britain, and are therefore a potential site of surgical TOPFA care.

What do the results of this study add? Women and National Health Service providers can be reassured that when a dedicated care pathway for TOPFA is employed in the context of routine abortion provision in the independent sector, the choice of termination method can be safely and satisfactorily increased.

What are the implications of these findings for clinical practice and/or further research? The main implication is the raising of awareness among NHS providers of the availability and acceptability of this model of TOFPA service delivery, so it can become an option for more women who do not want to have a medical induction. We hope that the demonstration of some women’s preferences for surgical TOPFA and the safety of this option will lead to development of this service within routine abortion lists within hospital settings. Further research could include determining the reasons why women and their partners may ultimately not choose to pursue a surgical TOPFA within the independent sector abortion service and an in-depth exploration of women’s experiences of being treated within this setting.

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Development of a national referral centre for surgical abortion at Homerton University Hospital

by Deshveer Singh Babra, Richard Lyus, Benjamin Black, Cathy Roberts, Edgar Kennedy Dorman, Tracey Masters

BMJ Sexual & Reproductive Health  DOI: 10.1136/bmjsrh-2019-200368  (Not open access)

Key messages

  • In the UK there is inadequate provision of hospital-based abortion services, causing delays, difficulties, and denial of care for women with medical problems seeking to access a termination of pregnancy.
  • Surgical abortion by dilatation and evacuation is frequently the optimal method of abortion for women in the second trimester with complex medical problems, but availability of this procedure is especially limited.
  • We demonstrate the feasibility of expanding a hospital-based abortion services to accept referrals from across the UK. Other units, with the support of commissioners and the relevant national bodies, should consider doing the same, to ensure women are able to access care and are not forced to continue unwanted pregnancies that endanger their health.

Abortion services in the UK are increasingly commissioned within the independent sector. This has improved accessibility and lowered costs for the care of women who have no significant medical problems, but creates access problems for women requiring hospital-based abortion care, as hospital-based National Health Service (NHS) units lose funding and cease to operate. To indicate the scale of need for hospital-based abortion care, The British Pregnancy Advisory Service, an independent-sector abortion provider, has reported that in 2016 and 2017 it arranged referrals to NHS providers for 2,900 women. Due to the shortage of hospital-based services, particularly those offering care in the second trimester, these patients often have to wait several weeks for a referral to be accepted and may face a further wait until their appointment. They also may need to travel large distances. A significant minority of these women are unable to access abortion at all and are forced to continue pregnancies they would almost certainly be eligible to terminate within the UK legal framework. These ongoing pregnancies will furthermore be complicated by the same condition that complicates their abortion.…

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Lifesaving treatment for babies born at 22 weeks doesn’t mean abortion law should change

by Dominic Wilkinson, Consultant Neonatologist and Professor of Ethics, University of Oxford

The Conversation, 25 October 2019 (Open access)

When new guidance relating to the outcome and medical care of babies born extremely prematurely was recently released, it led some to call for UK abortion law to be revised. 

This was because one of the new recommendations from the British Association of Perinatal Medicine is that it is sometimes appropriate to provide resuscitation and active medical treatment for babies born at 22 weeks gestation (four and a half months before their due date). This is a week earlier than was recommended in the last version of the framework, published in 2008.

The argument goes that the new guidance creates a “contradiction in British law” because extremely premature infants can now be resuscitated before the point in pregnancy where abortion law changes. 

One reason not to review the law is that the fundamental issues have not changed overnight, or indeed over the last 20 years. It has been possible for more than two decades for extremely premature infants before the 24-week cut off point to survive.

While some claim that the law is contradictory, there is, in fact, no inherent contradiction. It is true that doctors will attempt to save the lives of some babies born before 24 weeks, where that is what parents wish. However, the very high risk of mortality or very serious complications means that intensive care treatment is not always provided. If parents do not wish for their baby to receive intensive treatment it is ethical to provide palliative care at delivery, and the revised framework supports this. 

This reflects the ethical importance of respecting the wishes of parents when it comes to treatment that is so risky and uncertain. Arguably, if a woman decides not to continue a pregnancy at 22 or 23 weeks’ gestation, and obstetricians support this choice, that is completely consistent with the ethical framework that applies in newborn care.

The important question that underlies all of this is why the law relating to abortion should have a 24-week cut off in the first place. The current law appears to be based on the idea that “viability” changes the ethical considerations around abortion. 

It is also often deeply unclear both what is meant by “viable”, and why this is relevant to the ethics of abortion.

Is a 22-week fetus/baby viable? They could survive – if their parents want to undergo highly intensive treatment, and if that treatment is available (in most parts of the world it isn’t). However, three out of four babies will not survive, even if this is attempted. Some might regard such infants as viable, while others would not.

Viability doesn’t affect the ethics of abortion.

While pro-life advocates are opposed to termination of pregnancy at 23 weeks, they are also opposed to abortion occurring at 20, 16 or 12 weeks. Viability is of no relevance if you have the view that the fetus has a right to life. On the other hand, those who support women’s right to choose sometimes argue that abortion should be allowed past 24 weeks. The importance of respecting a woman’s autonomy does not change just because a fetus could, in theory, survive if they were born prematurely and actively treated… (article continues)