Dorries’ amendments blown apart by RCPsych review

Let’s recap where we are here.

Last week, Nadine Dorries put forward two amendments to the Government’s highly controversial Health and Social Care bill.

If accepted by parliament these amendments would have the effect of preventing independent abortion service providers, such as BPAS and Marie Stopes International, from providing pre-abortion counselling to women who are considering or actively seeking to terminate an unwanted pregnancy and would, in addition, strip the Royal College of Obstetricians and Gynaecologists (RCOG) of their current responsibilty for preparing and publishing clinical guidance for doctors on the care of women seeking an abortion.

As should be evident from my own exposé of the hidden agenda behind these amendments, Dorries is, once again, attempting to use her position as a Member of Parliament to assist in implementing a gradualist strategy devised by an alliance of vehemently anti-abortion organisations with the ulimate aim of prohibit abortion in the UK under any circumstances, including rape, serious foetal abnormality and even serious risk to a woman’s life.

One of the presentation slides highlighted in that last post if particularly relevant to these amendments inasmuch as it shows anti-abortion campaigners setting out to deliberately target both RCOG and the Royal College of Psychiatrists (RCPsych) with the stated objective of ‘changing medical opinion’, specifically the Royal College’s guidelines on the psychological effects of abortion.

Any hopes of leaning on RCOG were dashed in January of this year with the publication of its revised draft guideance on the ‘Care of Women Requesting Induced Abortion’ – both Royal Colleges had been asked to update the guidance by the House of Commons Science and Technology Committee following the publication of its November 2007 report on ‘Scientific Developments relating to the Abortion Act 1967‘.

As with all of RCOG’s recommendations in regards to the information that should be given to women during pre-abortion counselling, its recommendation that women should be informed that ‘most women who have abortions do not experience adverse psychological sequelae’ was supported by a paragraph outlining the evidence on which the recommendation was based, all of which was derived from four systematic reviews of the evidence relating to abortion and mental health published between 2008 and 2009.

In essence, therefore, what we have on our hands is a coordinated revenge attack on RCOG, the full scope of which can be clearly seen by reading Dorries’ amendments in conjunction with EDM 1662, which was tabled by Jim Dobbin MP, a Roman Catholic and former chairman of the All Party Pro-Life Group:

That this House notes that the Consultation Committee and Report of the Royal College of Obstetricians and Gynaecologists (RCOG) The Care of Women Requesting Induced Abortion fails in at least four criteria required by the Government Code of Practice; further notes that the Leader of the House has stated that the Government could not interfere because it was a RCOG Consultation Committee and not the responsibility of the Government (17 February 2011, Official Report, column 1145); further notes, however, that in the Answer to Lord Alton of Liverpool, Official Report, House of Lords, column WA425, the Governmentstated that the Department of Health commissioned and funded the review; further notes with grave concern, therefore, that the committee considering the review allowed only21 days for consultation instead of at least 12 weeks as required by the Government’s guidelines and that the membership consisted almost entirely of pro-abortion personnel including representatives from the UK’s two main abortion providers, the British Pregnancy Advisory Service (BPAS) and Marie Stopes International; further notes it was not until a press release from BPAS quoted the guidelines and implied that they had been finalised that it became known to a majority of interested parties that the consultation existed, by which time there were only five days for interested parties to respond; further notes that the present guidelines include a number of claims which peer-reviewed medical literature suggest are inaccurate or misconstrued; and calls on the Government to establish a further consultation with a balanced membership under the National Institute for Health and Clinical Excellence which will be answerable to Parliament.

The EDM is factually inaccurate inasmuch as the consultation period set by RCOG was 28 days and not 21 days. The draft guidelines were published on 22nd January 2011, with a closing date for submissions of 18th February, this being RCOGs standard timescale for a peer review of draft clinical guidelines.

Yes, that is correct.

The guidelines were published for peer review by RCOG members and other relevant clinical specialists and not as part of a public consultation on patient information for which RCOG’s standard consulation period is a minimum of 12 weeks, rendering the EDM’s criticism of the consultation process invalid.

Beyond that we have the usual accusations of bias – remembering that bias in this case mean anything that doesn’t support the anti-abortionists arguments, including the scientific evidence – and demands for a review conducted by a ‘balanced’ membership under the aegis of the National Institute for Health and Clincial Excellence (NICE), and by ‘balanced membership’ the EDM’s suppiort mean, of course, one that includes anti-abortionists on the review panel irrespective of whether they have the clinical expertise or robust approach to evidence necessary to contribute anything other than the usual ineffectual whining when their junk science is rejected as misleading and lacking in credibility.

As for the alleged inclusion of innacurate and/or misconstrued claims in the guidance, this aleegation almost certainly relates to the contents of the Christian Medical Fellowship’s submission to RCOG’s consultation which, amongst other things, continues to peddle misleading claims of a link between abortion and breast cancer on the basis of just two papers, the most recent of which is 10 years old and was published by an anti-abortion website and not in a peer reviewed journal. The author of this paper, Patrick S Carroll, did eventually get a paper published in a journal in 2007, but only after submitting his work of JPANDS. The quality of Carroll’s research is discussed here by Mark Chu-Carroll (definitely no relation) who offered this conclusion on Patrick Carroll’s efforts to model an association between abortion and breast cancer:

The model is wrong. Invalid models to not produce valid results. Stop. Do not pass go. Do not collect $200. Do not get your paper published in a decent journal. Do get laughed at by people who aren’t clueless jackasses.

The other paper put up for consideration by the CMF is a 1996 paper by Joel Brind (not 1997 as stated by CMF) which was heavily criticised by researchers from a German Cancer Research Centre:

The results of this meta-analysis seem to be strongly biased towards a positive effect-mainly due to the way studies were selected. Standard statistical methods that are available for meta-analysis (see, for example,2), in particular for the investigation of heterogeneity, were not used. We feel that it is unethical and harmful to publish such data
as definitive results or facts of “meta-analysis” from observational studies when only a pooled estimate (with 95% confidence interval) is calculated, without investigating the heterogeneity between studies. Results from meta-analysis are often used and cited for further research and for implementing public health policies. In general, meta-analysis using only published data from epidemiological (observational) studies and not the original data set should be treated with caution. Some authors even argue that such a meta-analysis cannot yield reliable results
in the presence of heterogeneity.

The conclusions drawn in the work of Brind et al are not based on a methodologically sound investigation and are therefore not justified.

As ever, the CMF’s submission makes no mention whatsoever of any of the large scale studies or systematic reviews published since Brind’s paper:

The largest, and probably the most reliable study on this topic was done during the 1990s in Denmark, a country with very detailed medical records on all its citizens. In that study, all Danish women born between 1935 and 1978 (a total of 1.5 million women) were linked with the National Registry of Induced Abortions and with the Danish Cancer Registry. All of the information about their abortions and their breast cancer came from registries – it was very complete and was not influenced by recall bias.

After adjusting for known breast cancer risk factors, the researchers found that induced abortion(s) had no overall effect on the risk of breast cancer. The size of this study and the manner in which it was done provides good evidence that induced abortion does not affect a woman’s risk of developing breast cancer.

Another large, prospective study was reported on by Harvard researchers in 2007. This study included more than 100,000 women who were between the ages of 29 and 46 at the start of the study in 1993. These women were followed until 2003. Again, because they were asked about childbirths and abortions at the start of the study, recall bias was unlikely to be a problem. After adjusting for known breast cancer risk factors, the researchers found no link between either spontaneous or induced abortions and breast cancer.

The California Teachers Study also reported on more than 100,000 women in 2008. Researchers asked the women in 1995 about past induced and spontaneous abortions. While the women were being followed in the study, more than 3,300 developed invasive breast cancer. There was no difference in breast cancer risk between the group who had either spontaneous or induced abortions and those who had not had an abortion…

…In 2004, the Collaborative Group on Hormonal Factors in Breast Cancer, based out of Oxford University in England, put together the results from 53 separate studies done in 16 different countries. These studies included about 83,000 women with breast cancer. After combining and reviewing the results from these studies, the researchers concluded that “the totality of worldwide epidemiological evidence indicates that pregnancies ending as either spontaneous or induced abortions do not have adverse effects on women’s subsequent risk of developing breast cancer.” These experts did not find that abortions (either induced or spontaneous) cause a higher breast cancer risk.

Having waded through the CMF submission, I should note that the selective use and omission of evidence illustrated above is entirely indicative of the organisation’s approach to scientific evidence across its entire submission.

The only line of attack not directly referenced so far is that of suggesting that RCOG should have waited for publication of RCPsych’s systematic review of the evidence on abortion and mental health before publishing its won draft guidelines:

The Royal College of Psychiatrists is publishing significantly revised guidance this spring. Surely, on such a vital matter, the RCOG should await the RCPsych guidance and amend this draft guidance in the light of that. [CMF submission to RCOG]

RCPsych have now published, in draft, their evidence review for consulatation and as anyone who is reasonably conversant with the literature will have expected, its bad news all the way for Dorries and her anti-abortion lobby buddies:

In summary, the following key points were identified by this review:

although there are significant limitations with the dataset included in this review, this review is perhaps a little more robust, combining the approaches of both main previous reviews, and confirms many of the findings in previous reviews.

mental health outcomes are likely to be the same, whether women with unwanted pregnancies opt for an abortion or birth

women with mental health problems prior to abortion or birth, are associated with increased mental health problems after the abortion or 22 birth

for all women who have an unwanted pregnancy, support and monitoring should be offered as the risk of later mental health problems are greater whatever the pregnancy outcome. The offer of support should depend upon the emergence of mental health problems, whether during pregnancy, post-abortion or after birth, and should be underpinned by NICE guidance for the treatment of the mental health problems identified

if women who have an abortion show a negative emotional reaction to the abortion, or are experiencing stressful life events, support and monitoring should be offered as they are more likely than others to develop a mental health problem.

RCPsych’s consulation is set to run until June and its review paper indicates that a number of researchers have already invited to provide submissions on the understanding that they may have as yet unpublished research to add to the comprehensive list of papers included in the review.

Given the exacting approach taken by RCPsych in its draft paper it is, however, highly unlikely that anything will emerge over the next couple of months to prompt them to substantially revise their findings and, as such, RCOG’s recommendations stand, although they should certainly amend their guidelines to incorporate RCPsych’s findings.

Whatever hopes the anti-abortion lobby might have had for RCPsych’s review, these have clearly now been dashed and it remains to be seen how they will respond. In the first instance, I would expect that RCPsych will received the usual rash of submission challenging the methodology and, particularly, the exclusion criteria used in their review, together with their evaluation and interpretation of the evidence contained in the papers on which anti-abortionists have been pinning their hopes of forcing RCPsych to shift its position on abortion and mental health.

On my own close reading of the review paper, such an approach will almost certainly prove to be futile, but it will likely still be vigorously pursued, if only to provide spurious justification for the inevitable allegations of bias that will be directed toward RCPsych when it fails to bend to pressure and stands by the evidence.

If Dorries had any shred of decency, at all, she would now withdraw her amendments, as the RCPsych review has comprehensively and systematically demolished her entire position to the extent that all she has left are the unfounded and frankly libelous smears she’s been directing toward BPAS and Marie Stopes International.

However, this is Dorries we;re dealing with here, which means that its much more likely that she’ll respond by subjecting RCPsych to precisely the same scurrilous treatment that she’s visited on RCOG, with the possibility that she may even go so far as to submit further amendments with the aim of conducting a similar legislative revenge attack on RCPsych as that which RCOG currently faces.