Ethics

Reasons for nurse and GP abortions

Reasons for allowing nurse abortions or abortion in GP surgeries include:

• Convenience – GP surgeries are closer to home. This is the stated reason.
• Necessity – Fewer and fewer doctors are happy to perform abortions. The Royal College of Obstetricians and Gynaecologists warned last year that low numbers of trainees may jeopardise abortion services[1], and claims have emerged more recently that many private sector abortion clinics are staffed mainly by foreign-trained doctors on short-term contracts.[2] Allowing nurses to perform abortions would ease these staffing problems.
• Cost – medical abortions are cheaper. The table below contains pricing information from the British Pregnancy Advisory Service (BPAS)[3], who carry out 48,000 abortions each year of which 60% are paid for by the NHS.[4] Marie Stopes, the other leading abortion provider, has similar prices.[5] As can be seen the prices of surgical abortions are substantially higher. The price of medical abortions would fall still further if they could be carried out in non-specialist GP clinics by nurses, and if completion at home is possible.

Because of these benefits, the Department of Health has already begun two trials of offering abortion services in selected GP surgeries.[6]

Nurse and GP abortions are a bad idea and can be opposed on the grounds of safety, legality and the effects on society.

Safety concerns

The key issue here is medical versus surgical abortion procedures:

• Surgical abortions represent 65% of the abortions carried out in 2007. They are carried out by vacuum aspiration (suction) in over 90% of cases, and by dilatation and curettage in almost all of the remaining cases.
• Medical abortions (35% of the total in 2007) are carried out by taking first the drug RU-486 (mifepristone) and then a prostaglandin, most commonly misoprostol. They may require up to four visits to the abortion clinic. Almost all very early abortions (3-4 weeks) and late abortions (24 weeks, after foeticide), are carried out this way, as well as a proportion of abortions at all gestations. [7]

Abortions carried out by nurses, or carried out in GP surgeries, would have to be medical abortions (surgical abortions require trained surgeons and operating theatres). There would be the potential for the second pill to be taken at home.

This would have three main consequences for women's health:

• The proportion of women having medical abortions would increase: these are linked with higher complication rates (see below).
• These complications would not be recognised and treated so effectively if not supervised by doctors in fully equipped medical facilities.
• These measures would improve accessibility of abortion which may increase the numbers of abortions generally, raising the number of women exposed to all the health risks of abortion generally.

Medical abortions have a much higher rate of complications than surgical abortions. According to 2007 England and Wales abortion figures, complication rates before discharge from hospital for medical abortion were nearly twice those of surgical abortion.[8]

• A recent large-scale Danish study compared patient satisfaction after medical and surgical abortions.
• Severe pain was experienced by 40% of those undergoing medical termination compared to 6% undergoing surgical termination,
• Severe bleeding by 36% after medical terminations compared to 1% after a surgical procedure.
• Surgical abortions also produced considerably less severe nausea, vomiting and dizziness,
• Surgical abortions had a 98% success rate compared to 94% success with medical abortions.
• Overall, women having surgical abortions were significantly more satisfied with the procedure than those having medical abortions.[9]
• Complications for which hospitalisation is required are more than twice as likely after a medical abortion as compared to a surgical one.[10]
• Pelvic Inflammatory Disease (an ascending gynaecological infection which is Britain 's commonest cause of infertility) occurs in about 1% of cases of medical abortion.[11]
• In North America, there have been at least 6 maternal deaths from septic shock after medical abortions, because mifepristone may predispose the endometrium to infection.[12]
• In June 2005 a teenager died in Wales following a medical abortion which went wrong, resulting in severe bleeding hypovolaemic shock.[13]

In addition to the risks above specifically linked with medical abortions, all abortions carry common health risks including risks to the woman's subsequent mental health. The Royal College of Psychiatrists has said the following in its March 2008 position statement on abortion and mental health: 'Healthcare professionals who assess or refer women who are requesting an abortion should assess for mental disorder and for risk factors that may be associated with its subsequent development. If a mental disorder or risk factors are identified, there should be a clearly identified care pathway whereby the mental health needs of the woman and her significant others may be met.'[14] Nurses are not trained in recognising mental illness and so are not in a position to carry out adequately the requirements for the Royal College's guidelines, in identifying patients at high risk of subsequent mental health problems.

The safest and most humane way to carry out abortion is to have surgical abortions carried out in specialised clinics under general anaesthetic. As well as risking the complications outlined above, medical abortion with completion at home leaves the woman with the traumatic task of disposing of the dead baby.

Legality

In Britain abortion remains illegal, carrying up to a 14 year custodial sentence, except in those circumstances specified in the Abortion Act. The Offences Against the Persons Act (1861) grants the unborn child legal protection, and doctors are only exempt from prosecution when they terminate a pregnancy within the terms of the 1967 Act. Two doctors' signatures are required, who should 'police' each other to ensure that the terms of the Act are upheld.

Allowing nurses to perform abortions would greatly alter the nature of the Act. Currently abortion is counted in law as a 'special case' (as with cremation, or detaining a patient under the terms of the Mental Health Act), requiring two medical opinions. Allowing nurse abortions would make the legal requirements for abortion lower than those of 'normal' medical procedures (which all require a doctor's signature). Abortion would become special among medical procedures not because the legal requirements for consent are higher than for other procedures, but because they are lower. The whole medicolegal framework for abortion would be considerably changed.

Effects on society

Abortion is the only 'medical' procedure which involves the intentional destruction of human life. Nothing should be done which reduces the seriousness in which people choose to have an abortion. Allowing abortion outside the currently designated premises, to be performed by nurses and midwives, raises the frightening possibility of high-street abortion clinics which women could attend without ever seeing a doctor.

The issue of conscientious objection must also be borne in mind. A survey in the GP magazine Pulse in 2007 found that 24% refuse to sign abortion forms.[15] The effects of allowing abortions in surgeries may be intolerable for pro-life members of staff (including nurses, receptionists, cleaners and anyone else who may consider that working at the practice makes them complicit in the process of abortion). Furthermore, at least some patients at every GP surgery in the country will have strongly held views against abortion, and expecting them to attend surgeries where abortions are carried out in the next room is unacceptable.

BMA

The BMA opposes both nurse abortions and abortion in GP surgeries. Motions to approve both were defeated at the 2007 Annual Representatives Meeting, largely on safety grounds.[16]

Conclusion

Nurse and GP abortions:

• Would be more dangerous, uncomfortable and traumatic for the women undergoing them than for women having surgical abortions
• Would change the whole nature of abortion law in this country, making it a procedure with one of the lowest standards on informed consent of any medical procedure
• Would trivialise abortion and challenge the rights of NHS staff and patients to work or be treated in institutions away from the practice of abortion