The ‘new’ guidelines on abortion from the RCOG

Just as the leopard cannot change its spots, nor does it seem that the RCOG can change its controversial stance with its revised guidelines for the care of women requesting abortion.

The Royal College of Obstetricians and Gynaecologists (RCOG) guidance on ‘The Care of Women Requesting Induced Abortion’ was first published in 2000. An updated version followed in 2004 and this guideline served until this revision which took place during 2010 and 2011.

Their guidelines on abortion have always generated controversy. They are authored by a ‘multi-professional group’ consisting of representatives from the RCOG, the RCOG’s Faculty of Sexual and Reproductive Health (FSRH), the Royal College of General Practitioners (RCGP), and the abortion industry (namely the two largest abortion providers BPAS and Marie Stopes International). The participants are almost exclusively ‘pro-choice’. There are no psychiatrists on the panel, despite their review of the evidence on the psychiatric effects of abortion.

We had expected that the guidelines would be published after the Royal College of Psychiatrists (RCPsych) issues its own in-depth review on the effects of abortion, which it consulted on this summer.  But clearly the RCOG decided it would get in first, despite whatever the RCPsych  might recommend, and push its own agenda instead.

These latest guidelines have been issued after minimal consultation and a distinct lack of transparency in the consultation process (‘consultation’ perhaps stretches the meaning of the word since the draft was simply posted on their website for 25 days) thus very few stakeholders apart from those with a close connection to the abortion industry were aware of the consultation or the peer review process.

Of most concern, however, is that the research and recommendations in these guidelines still underplays the physical and psychological consequences of abortion for women, as well as the link with pre-term births and breast cancer.  Indeed, much of the report reads like a paper that representatives from the abortion industry might produce (not too far fetched a suggestion since several of the group are directly linked to the abortion industry).  Which is a real worry, considering that these guidelines will be highly influential in both policy and practice.

Among the document’s recommendations are the following:

‘Women should be informed that abortion is a safe procedure for which major complications and mortality are rare; Women should be informed that induced abortion is not associated with an increase in breast cancer risk; Women should be informed that there are no proven associations between induced abortion and subsequent ectopic pregnancy, placenta praevia or infertility; Women should be informed that induced abortion is associated with a small increase in the risk of subsequent preterm birth…however, there is insufficient evidence to imply causality; Women should be informed that the evidence suggests that they are no more or less likely to suffer adverse psychological sequelae whether they have an abortion or continue with the pregnancy; Women with a past history of mental health problems should be advised that they may experience further problems whether they choose to have an abortion or continue with the pregnancy.’

These are pretty much along the same lines as in previous guidelines. So what is new in these ‘revised’ guidelines?  First, there is a new statement that:

‘ “Women should have access to counselling and decision-making support, however, women who are certain of their decision should not be subjected to compulsory counselling. ” ‘

Those who followed the summer parliamentary debates on the offering of counselling  to women considering abortion will appreciate that this appears to send a clear warning against extending the availability and offering of counselling to women. The authors can only bring themselves to recommend that counselling should ‘be available’, if women request it: ‘ “Women should have access to objective information and, if required, counselling and decision-making support about their pregnancy options.” ‘

Our concern is of course that many women will not ask for, nor access, any counselling for a number of reasons, including feelings of regret, guilt and shame.  The immediate sense of relief many women feel after their abortion can often give way to regret, and worse, which is why women need to know who to approach for counselling and help, not just immediately but in the longer-term too.

Second, the information on mental health is updated and now acknowledge that some women with a prior history of mental illness are at greater risk:  ‘ “Providers should be aware that women with a past history of mental health problems are at increased risk of further problems after an unintended pregnancy.” ‘

However this, they claim, is equally true for those who continue with the pregnancy, thus implying that abortion can be treated the same as continuing with the pregnancy.

For a set of professional guidelines, the data and research referenced to back up their recommendations are hardly robust and comprehensive.  Just six papers – including the RCPsych review (in press) – were referenced to reinforce  the claim that there are no significant mental health consequences post-abortion compared to pregnancy.  They ignored any research (even some included in the RCPsych draft review) that shows evidence of higher rates of mental health problems post-abortion for women with no prior history of mental health problems, compared to women in the general population.

They also ignore highly respected research by Fergusson, as well as new research by Coleman published in the British Journal of Psychiatry, covered in more detail here. In fact, Coleman’s findings could hardly be more different to those of the RCOG. She shows that women with an abortion history experience nearly double the risk of mental health problems when compared with women who had not had an abortion.  Moreover, despite what the RCOG guidelines claim, even when compared to women delivering an unintended pregnancy, post-abortion women still had a 55% increased risk of experiencing a mental health problem.

There have been a series of large scale, well-controlled studies using sophisticated data analysis methodologies articles published across the globe (US, Canada, New Zealand, Australia, Norway, and South Africa) in recent years which directly contradict the findings cited in the RCOG report, in that they consistently confirm a relationship between abortion and psychological distress that this, and other, national professional organisations have dismissed.

Third, these revised guidelines do acknowledge: ‘ “…that induced abortion is associated with a small increase in risk of subsequent preterm birth, which increases with the number of abortions.” ‘ The problem is, the risk is not small.  The RCOG report presents evidence suggesting that the increased risk of preterm delivery is 27%-62%.  Moreover the risk increases with each abortion. Induced abortion is therefore associated with a significant risk of subsequent preterm birth.  Research they do not cite looked at more than a million pregnancies in Scotland over 26 years and found that women who have had one termination are 34% more likely to have a premature birth than those pregnant for the first time. Their chances of pre-term delivery are 73% higher than women having a second baby, who are known to have a lower risk of preterm delivery.

While there is much more that could be said about these guidelines, the timing of publication provides an interesting concluding twist to the tale.  On the same day, Christian Concern reported on new Parliamentary figures which detail the millions of pounds that go to abortion providers. £44m was paid to NHS bodies, whilst £75m went to private clinics, providing a total of £118m spent on abortions in 2010!  This is nearly £30m more than previously thought.  While I am not suggesting any monetary link to the RCOG itself, these figures highlight the multi-million pound link between the referral agencies and the abortion industry. The same people are providing both ‘pregnancy advice’ and abortion.  Unless this link can be severed the ability of women to be sure that the advice and information that they receive is untainted by the vested interests of abortion providers remains an illusion. The stranglehold of the abortion industry has been covered in more depth here too.

Given that the BPAS and MSI abortion centres are both represented on the RCOG group, and these centres make up the vast majority of abortion providers, surely the question can justifiably be asked whether they are capable of ensuring that women are fully informed about all the effects and risks of abortion, about where to obtain counselling and about the choices available to her, including alternatives.

Posted by Philippa Taylor

CMF Head of Public Policy