Women have a right to know

… the truth about Nadine Dorries’s latest anti-abortion campaign.

Yes, I know I should be getting on with fixing up the Ministry but an issue has arisen that merits my attention, namely Nadine Dorries’ latest attack on women’s abortion rights:

A cross-party alliance of MPs will launch a fresh bid to tighten the rules on terminations.

Nadine Dorries, a Conservative MP, and Frank Field, a former Labour minister, will table amendments to the Health and Social Care Bill now passing through the Commons.

Supporters of the amendments say that passing them would lead to a dramatic reduction in the number of abortions that take place in the UK.

Dorries is pursuing this latest batch of unwanted and unnecessary amendments with all her usual visceral unpleasantness, breathtaking stupidity and charmless dishonesty.

The focal point of her attack, this time around, is the provision of pre-abortion counselling by organisations that also provide abortion services:

The first amendment would create a new precondition for any women having an abortion to receive advice and counselling from an organisation that does not itself carry out terminations.

And her motives are easily uncovered if only one takes the time and trouble to view the Trustees report in the most recent accounts of an organisation called Christian Action Research & Education (CARE):

CareConfidential delivers high quality, free, unconditional care and support to those faced with an unplanned pregnancy or child loss issues…

There are currently 153 independent pregnancy crisis centres in the CareConfidential network.

It’s a Trojan horse amendment which aims to prevent women receiving pre-abortion counselling from reputable, non-judgemental, organisations such the British Pregnancy Advisory Service, Marie Stopes International and even the NHS itself, in the expectation that this will force women into networks such as that operated by CARE under the ‘CareConfidential’ brand name.

The problem with this, notwithstanding the lies and smears that Dorries is relying on to make her argument, is self-evident when one examines CARE’s charitable objects:

The advancement and propagation of the Christian gospel and in particular Christian teaching as it bears on or affects national and individual morality and ethics.

While CARE’s main website is perfectly open in describing its relationship with CareConfidential, the latter makes no direct mention of its relationship with its parent organisation or of its religious foundations;  although these can be traced, with a little effort, from CareConfidential’s ‘About Us’ page, which does at least cite CARE’s company and charity registration numbers.

CARE’s main website is, however, noticeably reticent on the subject of its core views and opinions on abortion, although it does state that ‘abortion information and abortion facts are available’ on the CareConfidential website, so its only when you do a little digging that you discover that, in 2001, CARE was one of four organisations that, along with the Catholic Church and Ian Paisley’s Free Presbyterian Church, openly opposed a legal challenge to Northern Ireland’s pre-1967 abortion law mounted by the Family Planning Association.

Q. Is there particular opposition in Northern Ireland to changing the law?

The Catholic Church and four pro-life organisations have declared themselves against moves to liberalise abortion legislation and want to become involved in the legal challenge brought by the Family Planning Association.

The groups are the Society for the Protection of Unborn Children (SPUC), Christian Action Research and Education (CARE), LIFE and Precious Life.

Ian Paisley’s Free Presbyterian Church is also against attempts to change the law. In 1984 the Northern Ireland Assembly voted against the introduction of the Abortion Act or any like legislation to Northern Ireland.

Equally revealing, if quietly buried on its European website, is CARE’s response to the EU’s Sandbaek Report on the provision of aid in support of reproductive rights in developing countries, which states:

CARE supports the provision of contraceptive services for couples who seek to limit the number and timing of children conceived by them for whatever reason. We support the funding of such services as part of EU overseas aid programmes where the Governments of the developing countries concerned have given this priority. However, because we believe that all human life is sacred we cannot condone the taking of measures to destroy human life after conception.

It should come as no surprise whatsoever, therefore, that the abortion ‘information’ provided by CareConfidential’s website is unremittingly negative and focuses solely on the risks associated with the procedure while its abortion ‘facts’ includes a research section which continues to promote discredited claims linking abortion and breast cancer and which relies heavily on the questionable output of Priscilla Coleman and David Reardon* of the Elliot Institute.

*For the record, and contrary to claims made on some anti-abortion websites, Reardon is not a Professor and does not hold an academic post with any credible teaching or research institution. He does claim to have a PhD in Bioethics but this was obtained from what was, at the time, an unaccredited correspondence college. He does, however, write batshit insane commentaries on abortion.

CARE’s claim that it provides non-judgemental crisis pregnancy services via its CareConfidential network is, to put it mildly, highly questionable given its real, but carefully concealed, views on abortion…

…but then that’s the point of this particular amendment, which aims to propel women into the clutches of these Christian run organisations in the hope/expectation that they’ll actively dissuade women from choosing to have an abortion, a practice that by any reasonable standards would, and should, be considered unethical.

At first sight, Dorries’ second amendment could easily be taken to be motivated by nothing more than sheer spite, given her long history of smearing anyone who disagrees with her:

The second amendment that will be tabled next week would strip the Royal College of Obstetricians and Gynaecologists of its role setting clinical guidelines on abortions.

Instead, the National Institute for Health and Clinical Excellence should advise doctors on when to allow an abortion, the MPs believe.

The RCOG is currently drawing up new clinical guidelines for terminations. Anti-abortion campaigners say the college is biased towards favouring abortion and should not be allowed to set the rules.

Writing on an internet blog, Miss Dorries said the college had “failed to uphold the principle of professionalism and ethical responsibility in the way it has behaved in the production of these guidelines.”

Dorries’ ‘charges’ against RCOG are as laughable as they are dishonest:

1. Of the eighteen members in the working group who have drawn up the draft guidelines, eleven are immediately and easily identifiable as abortionists who make their living wholly or partly through the abortion process.

2. The working group produced its draft guidelines for consultation and did so via its website with a four week deadline for submissions and comments, but failed to inform anyone it had done so, including stakeholders and journalists whose work had been quoted. With an issue as emotive as abortion, any professional and ethical group would have widely sought external opinion and would have ensured that the public had full access and scrutiny of the work undertaken. Government guidelines for consultation are twelve weeks. With an issue as important as this, the consultation period should have been double that.

3. The draft guidelines failed to include a declaration of interests from members of the group including a declaration of monies acquired through abortion industry related activities. The public have a right to that at the very least.

Points 1-3 amount to nothing more that the usual dull-witted smears and whinging about alleged bias.

The review panel for this consultation, which Dorries described as a ‘working group’, consists of representatives from RCOG, RCOG’s Faculty of Sexual and Reproductive Health (FRSH), the Royal College of General Practitioners, the British Pregnancy Advisory Service and Marie Stopes International.

As a professional review group made up of specialist working in the field of sexual and reproductive health of course it includes a number of members who are directly involved in the provision of legal abortion services. Its part of their field of expertise, which is why they’ve been asked to serve on a panel that’s been handed the responsibility of reviewing the current clinical guidance for induced abortions.

Make no mistake, this is a clinical guidance review and not a generic public consultation on the provision of abortion services, and so we can readily dismiss point 2 as mere dishonest whinging.

In this, as its other clinical guidance consultations, RCOG is primarily seeking the views of members (i.e. doctors) and other medical practitioners (i.e. more doctors, nurses and other clinical specialists) on the clinical evidence base relating to the provision of abortion services. As such, and based on the current content of RCOG’s consultations page, four weeks appears to be the standard timescale for consultations of this kind, with a longer period (12 weeks) allocated for consultations on patient information, where its reasonable to seek a wider range of opinion. If this practice has been found to serve RCOG well in other consultations, it surely has no need to alter its practices to suit the biased opinion of semi-hysterical idiot of an MP.

As for point three, Dorries is admitted something of an expert on conflicts of interest, having employed two of her daughters and a close personal friend to work in her parliamentary office at the taxpayers’ expense but, again, it has to pointed out that this is an expert review panel and one should therefore expect that a number of members will have worked in the abortion sector; how else would they have acquired their professional expertise in the field.

In making spurious allusions to alleged but unsubstantiated conflict of interest Dorries is merely continuing her dishonest line of ‘abortion industry’ smears against organisations and medical practitioners working in the field of sexual and reproductive health and, as ever, conducting herself in a manner entirely unbecoming of a Member of Parliament.

4. A review into the mental health impact of abortion upon women by the Royal College of Psychiatrists is presently underway. In producing its recent draft guidelines, the RCOG group has completely ignored the findings of a landmark study recently published in the British Journal of Psychiatry, that women who abort are 30% more likely to develop mental health problems than those who don’t and instead, has relied on a highly criticised review by the American Psychological Association.  It is logical to wait until the review by the Royal College of Psychiatrists has been produced before proceeding and further with the proposed RCOG guidelines.

Here we get to the meat of this entire issue.

Dorries’ real problem here is not that RCOG is biased against her position on abortion but rather that the clinical evidence fails to support her position and RCOG, as a reputable and diligent organisation, will have no truck with the anti-abortion lobby’s efforts to muddy up the waters by deliberately, and unethically, cherry-picking and misrepresenting the clinical and scientific evidence relating to abortion.

As regards the substantive points raised here:

It is perfectly true that the Royal College of Psychiatrists is reviewing its position statement on abortion and mental health and undertaking a systematic review of the current evidence base, having previously issued an interim update in 2008 after conducting a standard literature review:

Mental disorders can occur for some woman during pregnancy and after birth.

The specific issue of whether or not induced abortion has harmful effects on women’s mental health remains to be fully resolved. The current research evidence base is inconclusive – some studies indicate no evidence of harm, whilst other studies identify a range of mental disorders following abortion.

Women with pre-existing psychiatric disorders who continue with their pregnancy, as well as those with psychiatric disorders who undergo abortion, will need appropriate support and care. Liaison between services, and, where relevant, with carers and advocates, is advisable.

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.

RCOG is fully aware of the RCP review and, one would expect, has also solicited the RCP’s views in formulating it own guidance in addition to conducting its own review of the current literature on abortion and mental health and has concluded, based on the evidence, that it guidance should be revised as follows:

Recommendation 43

Women should be informed that most women who have abortions do not experience adverse psychological sequelae.

Evidence supporting recommendation 43

The great majority of women who have abortions do not experience adverse psychological sequelae. A systematic review of the evidence from 21 studies of abortion and adverse mental health outcomes did not support higher rates of a range of mental health outcomes in those who undergo abortion compared with their respective comparison groups, either women who delivered or women who had never been pregnant. Although the evidence in this area is conflicting, there are significant design flaws in many of the studies and those studies that do support a relationship between abortion and adverse mental health outcomes tend to be weaker methodologically. The evidence review by Major et al. (2009) [1] which updates the report of the American Psychological Association Task Force on Mental Health and Abortion, 2008 confirms that the most rigorous studies support the view that any observed associations between abortion and 2179 mental health problems do not appear to be related to abortion itself but to pre-existing conditions and co-occurring risk factors. Although abortion can be associated with a range of feelings, long term feelings of sadness, guilt and regret appear to linger in only a minority of women.

The first thing to note here is that the ‘landmark study’ that Dorries refers to point 4 – Fergusson et al. (2008) [2] – was just one of over a hundred papers referenced in Major et al. (2009), so it is entirely untrue to suggest that RCOG have ignored the paper’s findings.

As for the Major et al. review being heavily criticised, a search online failed to turn up any published criticism, which suggests that if any such criticism does exist it will have come from anti-abortion groups and from the likes of Priscilla Coleman and David Reardon, neither of whom can be considered credible sources.

As one might also expect, Dorries is being highly selective in her choice of citations, not to mention that she fails miserably to link to her primary source or to reference David Fergusson’s follow-up paper – Fergusson et al. (2009) [3] – which clarifies the findings of his previous paper. Fortunately, these omissions are easily corrected (see references at the end of this post) and as result we find that in his 2008 paper Fergusson arrived at the following conclusion:

The conclusions drawn above have important implications for the ongoing debates between pro-life and pro-choice advocates about the mental health effects of abortion. Specifically, the results do not support strong pro-life positions that claim that abortion has large and devastating effects on the mental health of women. Neither do the results support strong pro-choice positions that imply that abortion is without any mental health effects. In general, the results lead to a middle-of-the-road position that, for some women, abortion is likely to be a stressful and traumatic life event which places those exposed to it at modestly increased risk of a range of common mental health problems.

A position that he clarified in his 2009 paper, as follows:

Combining the findings of our two studies leads to the following generalisations about the links between unwanted pregnancy, abortion and mental health in this birth cohort.

a. First, unwanted pregnancy terminated by abortion was associated with modestly increased risks of common mental health problems for women who reported significant distress about the abortion (RR = 1.4–1.8).

b. Second, unwanted pregnancy terminated by abortion was not associated with significantly increased risks of mental health problems for women who did not report significant distress about the abortion (RR = 1.14–1.24).

c. Third, unwanted pregnancy that came to term was not associated with significant increases in mental health problems (RR = 1.05–1.11).

d. Finally, any associations between unwanted pregnancy, abortion and mental health problems were small to moderate, with adjusted relative risks in the region of 1.1–1.8. Estimates of the population attributable risk suggested that exposure to unwanted pregnancy terminated by abortion accounted for fewer than 5% of the mental health problems experienced by women in this cohort.

As we have noted previously, these findings are not consistent with strong pro-life positions that depict unwanted pregnancy terminated by abortion as having devastating consequences for women’s mental health. Equally, however, the findings do not support strong pro-choice positions that claim unwanted pregnancy terminated by abortion is without mental health risks. Rather, the accumulated evidence suggests that unwanted pregnancy terminated by abortion is an event that leads to significant distress in some women, with this distress being associated with a modest increase in risk of common mental health problems.

I don’t know about, but the reads to me very much as if what Fergusson is saying is that ‘most women who have abortions do not experience adverse psychological sequelae’, which is precisely what RCOG’s guidance recommends women seeking an abortion should be told.

One might also add that if, in Dorries’ opinion – not that that’s worth much – it is ‘logical to wait until the review by the Royal College of Psychiatrists has been produced before proceeding and further with the proposed RCOG guidelines’ then its would also be logical for parliament not to interfere with the provision of abortion services until such time as the RCP has finished, and published, its systematic review. Unless, of course, one is already fearful of the possibility – or rather near certainty – that the RCP review will not favour your position either. Nevertheless, it now seems that RCOG will delay publication of the final version of its new guidance until after the RCP have reported back on the ourcome of their systematic review, which seems a sensible move given that the review may add a little additional detail to RCOG’s own guidance.

Fergusson does go on, in both papers, to question the legitimacy of the practice of justifying abortions on mental health grounds, a legislative fudge common to both the UK and to New Zealand, where Fergusson is based (at the University of Otago) but then its hardly news that this practice is a legislative fudge that served, at the time that abortion was legalised, to provide a sop to the nervousness of some MPs and one that is now hopelessly outdated and, frankly, best dispensed with in favour of an honest acceptance that the overwhelming majority of abortions are carried out for legitimate social reasons.

5. The RCOG has failed to uphold the principle of professionalism and ethical responsibility in the way it has behaved in the production of these guidelines and indeed, I would go as far as to say has brought the entire RCOG into disrepute.

So say a former nurse whose medical qualifications would, today, just about make her suitable for a role emptying bedpans.

To be entirely clear about the politics of Dorries’ attack on RCOG and its role in setting clinical guidelines for abortion, stripping RCOG of this role and transferring the responsibility to NICE (National Institute for Health and Clinical Excellence) would serve two main purposes.

First, NICE’s stakeholder based consultation would potentially give anti-abortion groups a direct route into the consultation process.

NICE’s review system permits the inclusion of lay representatives from patient advocacy groups and charities on some of its consultation panels, so one could easily expect to see anti-abortion groups making a concerted effort to obtain recognition as stakeholders, were NICE to take on the responsibility for the clinical guidance on induced abortion, in the expectation that this would provide a platform from which they could influence the guidance in a direction more to their liking.

In practice, it is unlikely that this provide the anti-abortion lobby with the influence they desire. Although lay representatives may be appointed to NICE’s main review panels, its technical panels, which do most of the heavy lifting in terms of assessing the clinical/research evidence, remain very much the domain of clinical and research specialists. As the real issue here is that the evidence does not support the anti-abortionists position, the net result of transferring responsibility to NICE would only amount to a very public flounce by any anti-abortion panel members, when the evidence review failed to back up their position and they were not, after all, able to get their own way.

As a secondary purpose, NICE’s role is to be downgraded by the Health and Social Care Bill to that of an advisory body whose guidance can be readily modified or even ignored by the new GP commissioning bodies, these falling under the de facto control of the Department of Health and, by extension, the government ministers who determine the budget allocations awarded to these new organisations. There would, consequently, be far more scope for direct political interference in clinical practice, paving the way for a future US-style attack on abortion services, i.e. one that deliberately starves them of public funding.

Such an overt attack on abortion rights may well be some considerable way off in this country but the new NHS framework would, were this second amendment accepted, give the anti-abortion lobby a second bite at the same cherry that the first amendment is taking a bite at, even if that first amendment is rejected by parliament. In such a situation, the battlefield would likely shift away from parliament to the GP consortia, which would be inundated with anti-abortion lobbyists seeking both public funding for their own network of crisis pregnancy centres and locally imposed conditions on access to pre-abortion counselling of the same type and character as those contained in the first amendment.

To conclude, it’s worth reviewing what Major et al. have to say on the subject of the ‘interventionist fallacy’, which underpins this entire, fundamentally dishonest, attack on abortion rights:

The relationship between abortion and mental health is a highly contested issue. Some have claimed that a (presumed) negative relationship between abortion and mental health is a reason to make abortion less accessible. This argument is based on the reasoning that if abortion and a mental health problem (e.g., substance abuse) are related, then reducing access to abortion would reduce the prevalence of that problem. We would like to caution the reader against falling prey to this example of the “interventionist fallacy.” The interventionist fallacy results from the belief that if a relationship is currently observed between two variables, the form or magnitude of the relationship will remain unchanged if an intervention is instituted—for instance if the availability of abortion were to be dramatically reduced. As applied to the case of abortion, this reasoning (that if the number of abortions were to decrease, then there would be a proportional decrease in mental health problems) is flawed. One consequence of such an intervention would be that the characteristics of the population of women who delivered children would change. Characteristics previously more prevalent among women who have abortions (e.g., greater poverty, problem behaviors, exposure to violence) would now be more prevalent among women who deliver. Note that this potential change in the profile of women giving birth may include new mental health problems that might develop from stresses associated with raising a child a woman feels unable to care for or may not want or from relinquishing a child for adoption. Thus, reducing access to abortion could result in poorer mental health among the population of women who deliver. Hence, rather than reducing the prevalence of mental health problems among women, this intervention could potentially increase it.

Fergusson et al. suggest, convincingly, that women who experience significant distress when seeking an abortion are those most at risk of subsequent mental health problems, hence consideration needs to be given to the question of the causes of this kind of distress and, consequently, to the results of a small qualitative study by Goodwin & Ogden (2007) [4]:

The results showed that although a few women reported a linear pattern of change in their emotions, many also described different patterns including persistent upset that remained ongoing many years after the event, negative re-appraisal some time after the event and a positive appraisal at the time of the event with no subsequent negative emotions. The results also provide some insights into this variability. Those who described how they had never been upset or experienced a linear recovery also tended to conceptualise the foetus as less human, reported having had more social support and described either a belief that abortions are supported by society or an ability to defend against a belief that society is judgemental. In contrast, patterns of emotional change involving persistent upset or negative appraisal were entwined with a more human view of the foetus, a lack of social support and a belief that society is either overly judgemental or negates the impact that an abortion can have on a woman.

Some of the key factors that Goodwin and Ogden identify as being associated with persistent upset or negative appraisal following abortion (i.e. significant distress), a ‘more human view of the foetus’ and ‘overly judgemental’ social attitudes towards abortion are precisely the views and attitudes adopted and promoted by anti-abortion organisations to the extent that we can predict, with a reasonable degree of certainty, that any intervention that propels women into receiving ‘pre-abortion’ counselling from anti-abortion organisations it not only likely to increase the prevalence of mental health problems amongst those women who are persuaded not to go ahead with an abortion – this being the real objective of these so-called crisis pregnancy centres – as per Major et al. but also increase the risk of mental health in women who do choose to have an abortion after attending one of these centres as a direct consequence of these centres actively promoting views and attitudes that were found to cause women to experience significant distress by Goodwin and Ogden.

And yet Dorries and her backers still have the nerve to try and pretend that they are both ‘pro-choice’ and ‘pro-women’ when its perfectly evident that they are nothing of the sort.

References

[1] Major, B., Appelbaum, M., Beckman, L., Dutton, M.A., Russo, N. F. & West, C. (2009). Abortion and mental health: Evaluating the evidenceAmerican Psychologist, 64, 863-890.

[2] Fergusson, D. M., Horwood, L. J., & Boden, J. M. (2008). Abortion and mental health disorders: Evidence from a 30-year longitudinal study. British Journal of Psychiatry, 193, 444–451.

[3] Fergusson, D. M., Horwood, L. J., & Boden, J. M. (2009). Reactions to abortion and subsequent mental health.  British Journal of Psychiatry, 195, 420–426.

[4] Goodwin, P. & Ogden, J. (2007). Women’s reflections upon their past abortions: An exploration of how and why emotional reactions change over time. Psychology and Health, 22,2. 231-248. (abstract only)