MARGARET PYKE TRUST

Dr Jayne Kavanagh, Principal Clinical Teaching Fellow, UCL Medical School, London, tackled the sensitive and challenging issue of supporting women in making decisions about whether to continue with or to end a pregnancy. The aims of her talk were to explore how to conduct a clinically and legally robust consultation on abortion, how to enable honesty and trust in the consultation and how to identify and manage situations where patients might need extra support.

Dr Kavanagh began the talk by using the 2012 Telegraph newspaper sting, which led to three doctors being accused of authorising an abortion on the grounds of foetal sex, to clarify the legal status of abortion in mainland UK.

British law does not specify precise circumstances in which abortion is legal or not, she explained. The judgement about whether an abortion is lawful or not is left to the two authorising doctors who must decide whether individual women’s circumstances meet one of the five grounds outlined in the 1967 Abortion Act.

A total of 98% of abortions in this country are carried out under Ground C of the Abortion Act. This stipulates that abortions are permissible if two medical practitioners are of the opinion, formed in good faith, that the pregnancy has not exceeded its 24th week, and that the continuance of pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.

Dr Kavanagh went on to discuss the Director of Public Prosecution’s decision not to prosecute the doctors accused of authorising an abortion on the grounds of foetal sex because it was not in the public’s interest to do so. At the time he acknowledged that “many doctors feel that forcing a woman to proceed with an unwanted pregnancy would cause considerable stress and anxiety”, and that there was limited clear professional guidance for doctors on how to carry out and document a ‘sufficiently robust assessment’ of women who requested an abortion.

Dr Kavanagh discussed what made for a legally and clinically robust abortion assessment. She proposed 17 points:

1. Last menstrual period/ estimate gestation
2. Medical & sexual history
3. Assess STI risk and screen
4. Screen for DVA/ FGM/ safeguarding issues
5. Discuss/ prescribe contraception
6. Past and current mental health illness
7. Explore feelings about pregnancy / reasons for abortion
8. Check support (partner/ friends/ relatives)
9. Check sure about decision/ ambivalence
10. Assess risk of coercion
11. Ask about beliefs about abortion in general (if trigger)
12. Assess capacity (if trigger)
13. Outline options (parenting, abortion, adoption)
14. Outline different abortion methods/ risks
15. Explain how to access abortion
16. Refer/ sign abortion (HSA1) form
17. Give post-abortion information/ review

She then went on to discuss the role of clinician as gatekeeper to abortion in the UK. “What does the gatekeeper role entail? If a woman is sure she wants an abortion, then the clinician can facilitate a safe and quick abortion. While if there are doubts, it is to help a woman come to the right decision for her given her individual circumstances,” she said.

“The majority of women are sure about their decision and feel relieved following abortion,” said Dr Kavanagh. But she cautioned that there were some situations where extra support might be needed. Long-term psychological risk factors include previous and current mental health problems, pressure to have an abortion, ambivalence about an abortion, unsupportive partner and limited social support, or belonging to a religious, social or cultural group antagonistic towards abortion.

"Clinicians are more likely to be able to identify women who might need extra support, including those who are being pressurised to have an abortion if they explore women’s feelings about their pregnancy in a kind, non-judgemental and respectful way, avoiding the use of value-laden language and listening to women,” said Dr Kavanagh. “This engenders trust and enables women to ask questions and to express their feelings honestly and openly.”

Finally, Dr Kavanagh discussed how clinicians might best support women’s decision-making in three specific situations – when women were unsure about whether to continue or end the pregnancy, when they were under pressure to end the pregnancy, and when there were capacity issues.