This was going to be quite a straightforward article.
After all, how difficult could it be to dismantle the latest banal and ill-conceived witterings of Nadine Dorries, the sitting MP for the constituency of Mid-Narnia, on the subject of abortion and abortion law?
But then I ran into a problem, one that begins with the very first sentence of Dorries’ article:
Last week, the most recent EPICure study confirmed what many always knew; that if the NHS throws everything it has at saving the life of a premature baby born at 23 weeks gestation, there is an excellent chance of survival and an ongoing healthy life.
The problem is that there is no new EPICure study on which Dorries’ could hang this particular claim. The most recent paper published by the EPICure 2 research team made its first appearance in print six months ago and not in the last week or so – the publication date on the copy I have is actually March 6th 2014 – so just exactly what the hell is she referring to here?
Before getting into that I suppose I need to take a step back and explain exactly what EPICure is and the short version is that it’s an ongoing research programme which monitors and evaluates both the short and long-term health outcomes of extreme pre-term babies and by “extreme pre-term” what we mean are those born at between 22 and 26 weeks gestation.
The first EPICure study collected data on all births occurring at those gestational ages in 1995 and from every maternity unit in the UK and the Irish Republic producing, to begin with, statistics on mortality, morbidity and short-term health outcomes before going to conduct a series of follow-up studies on those children who survived being born at such an early gestational age at one year, two and half years, six years and, most recently, eleven years of age and there a two further follow-up planned, at 16 and 19 years of age, before the research programme comes to a close. So what we’re getting from EPICure, and will continue to get for a few years yet, is a pretty comprehensive picture of the impact of extreme prematurity ranging all the way from mortality and survival rates at birth through to discharge from hospital and to the long term effects on the physical and mental heath and neurocognitive development of children who do survive being born at such an early gestational age, all the way through into early adulthood.
It should, I think, be pretty obvious that that’s all really useful information for quite a number of different reasons.
In the years following the first EPICure study there were a number of changes made both to clinical practice in dealing with extreme pre-term infants and in the overall organisation of maternity services in England, particularly the reorganisation of neonatal services into clinical networks linked to tertiary hospitals with specialist neonatal intensive care units and 24 hour access to specialist staff; changes which, it was hoped, would lead to a reduction in mortality rates and the prevalence of long-term health problems and severe disabilities result from extreme pre-term births.
So, in 2006, a second EPICure study (EPICure 2) commenced, this time collating data on over 3,000 extreme pre-term births from a total of 186 consultant-led maternity units in England, the aim of which is, to evaluate whether or not any of the changes in clinical practice and service organisation since the first study in have actually led to any concrete improvements in survival rates and other key health outcomes. That’s a lot of data to pull together, process, analyse and prepare for publication, so it wasn’t until December 2012 that the first major publication from EPICure 2 appeared in print in the British Medical Journal but that paper – “Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies)” did indeed find that there had been some significant improvements in survival rates since 1995 where the birth took place at 24 or 25 weeks gestation and a more modest, but still welcome, improvement in survival rates at 23 weeks gestation but those findings come with a very important caveat:
Overall survival in 2006 has increased since 1995, although not significantly for births before 24 weeks’ gestation. This change results from improved survival to the end of the first week, with little difference thereafter. There is evidence of increased adherence to evidence based practice in 2006, which could account for improved condition of babies shortly after birth and explain improved outcomes in the first week. The prevalence of major morbidities in survivors, however, seems not to have improved either when evaluated alone or after adjustment for status within 24 hours of birth.
So, yes, a better survival rate overall but no change in the prevalence of major morbidities, i.e. serious disabilities, etc. where the risk for a child born at 23 weeks gestation exceeds 75%. Three out of every four babies born at 23 weeks gestation who survive to discharge from hospital into their parent’s care will have at least one major health problem or disability to contend with as they grow up.
The only other major set of findings from EPICure 2 to have been published, to date, are to be found in the paper that was published in March 2014 in another BMJ journal, the Archives of Disease in Childhood: Foetal/Neonatal Edition and that paper – “Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study” – looks at whether the type of maternity unit in which extreme pre-term births took place and whether or not the infant was then transferred to one of the large specialist units made any difference to the mortality figures and, perhaps unsurprisingly, it found that the most active specialist units with largest number of specialist consultants do produce the best overall survival rates but that, otherwise, there was no difference in the prevalence of major morbidities between survivors born in the different types of maternity unit encompassed by the study.
So that’s EPICure 2, at least to this point in time, but as I’ve already noted the most recent paper to emerge from study was published six months ago, so what exactly is this “study” that Dorries is referring to that she thinks was published only last week?
Well, the short answer is that it isn’t actually, it’s another badly misconceived and incompetently executed fishing expedition undertaken by a journalist working, on this occasion, for The Sunday Times, one that was published on 31 August 2014:
Abortion reform call as record number of babies survive birth at 23 weeks
Sarah-Kate Templeton, Health Editor
AT LEAST 120 babies born during week 23 of a pregnancy — the last week when abortions on demand are legal — have survived in the past four years, The Sunday Times can reveal.
New figures show the number of babies who are born before the 24-week legal abortion limit and survive is rising at large hospitals with specialist doctors. The real number of week 23 babies who survived is likely to be higher, as it is based on a sample of 25 hospitals that replied to a request under freedom of information laws.
The disclosure will revive the debate over the legal limit for abortion. In 2008, MPs voted against moves to reduce the limit to 22 or 20 weeks. Healthy babies can be aborted legally on demand up to 24 weeks into the pregnancy.
And that’s as much as we get before the Murdoch paywall kicks in but because lifting other newspapers’ stories is a way of life in the news media we can at least pick up more information about this story courtesy of the Daily Mail and, at the same time, explain exactly where Dorries got the idea that this was somehow a new piece of research from the EPICure 2 study, because the Mail’s article kicks off with an absolutely blatant error/falsehood:
A major study has revealed a record number of babies are surviving being born at 23 weeks.
The latest EPICure research showed at least 120 babies born during week 23 of a pregnancy have survived in the past four years.
Week 23 is the last week when abortions on demand are legal.
Figures from only 25 hospitals at large hospitals with specialist doctors were sampled, meaning the real number of week 23 babies who survived is likely to be higher…
At Central Manchester University Hospitals NHS Foundation Trust, six of eight babies born at 23 weeks and admitted to the neonatal unit for treatment last year survived.
At University College London Hospitals six of seven babies given treatment to save them survived. And at North Bristol NHS Trust all five born at 23 weeks last year also lived.
However, in 2011 figures show 565 babies were aborted at 23 weeks gestation. Nationally, the survival figures are even lower.
The EPICure study, published in 2012 and based on births in 2006, found that just 19 per cent of babies born at 23 weeks survived.
The research also found high levels of disability among babies born at 23 weeks. However, at some trusts where up to eight babies have been born at 23 weeks, none has survived.
Not only has EPICure 2 not captured any new data on extreme pre-term births since the end of 2006 but the The Sunday Times article clear states that its data was obtained directly from 25 hospitals using Freedom of Information requests. Whatever else the figures obtained by The Sunday Times might be, the one thing they most definitely aren’t are figures from the EPICure research programme even if that’s what the Mail are claiming in the second paragraph of their version of this story.
The obvious conclusion here is that the Mail’s version of the story is simple piss-poor cut and paste job by a jobbing journalist who’s clearly mailing it in and should probably consider moving on to do something that they actually give a toss about but that’s far from being the only major problem with this particular story, in fact there several problem all of which appear to stem from the fact that the journalist who put the story together clearly hasn’t understood any of the research that actually been published by the EPICure 2 team and quite possibly hasn’t even bothered to read any of it other than, perhaps, the abstract.
The first and most obvious problem is that The Sunday Times has obtained its figures from a hopelessly biased sample of just the largest and most active specialist units, contacting 25 hospitals, all of which have specialist neonatal units and that presents a major problem here because of the 186 maternity units included in EPICure 2, 46 were specialist tertiary units and 24 of those unit were classified as high activity units, in part because they more than four neonatal consultants. These are the units with the highest overall survival rates and they accounted for just under 64% of babies in EPICure 2 who survived to discharge, although we can’t be sure what proportion of those were born at 23 weeks gestation because the paper that provides this data doesn’t include breakdown by gestational age at birth.
What that means, of course, is that in obtaining it’s figures The Sunday Times has cherry-picked the biggest and best hospitals with the best overall survival rates which will inevitably give its readers a very biased picture compared to that provided by the actual EPICure study, which took its data from a much larger and more varied range of maternity units.
Even so, the figures that the paper came up with, 120 survivors born at 23 weeks gestation in the last four years, which is an average of 30 a year, amounts to less than half the number of babies (66) that were recorded by EPICure 2 as having been born at 23 weeks gestation in 2006 who then went on to survive to discharge.
So even after deliberately loading their figures with data from more than half of the best neonatal intensive care units in England, and these specialist units are only ones that properly equipped and staffed to deal with extreme pre-term infants, The Sunday Times has still managed to come up with a supposed “record” figure for the number of babies surviving to discharge after having been born at 23 weeks gestation that is less than half the actual figure reported by EPICure 2 for births in 2006.
There is a very good word for this and that word is “Bullshit”. The Sunday times hasn’t got the first fucking clue how its figures relate to those produced by actual research, they’re just claims that their figures are “record” just for the sake of fabricating a story out of nothing.
The other very obvious problem with the figures obtained by The Sunday Times is that the article doesn’t state explicitly on what basis those figures were supplied it is nevertheless perfectly evident that figures they’ve been given related only to babies who survived to discharge after being admitted to a neonatal ICU and that masks the fact that it is still the case that an awful lot of extreme pre-term babies just don’t make it that far.
This is a point that is perhaps best illustrated by using actual data from EPICure 2, in that case a graph showing the relative survival rates at 23 weeks gestation based on the number of foetuses/neonates that were still alive at different critical points up to and after the point at which those that did survive to discharge were admitted to a neonatal ICU.
So what this graph illustrates is exactly how the survival rate for babies born in England at 23 weeks gestation in 2006, expressed as percentage, will change according to nothing more than which point in the process, starting with the point at which the mother is admitted to hospital, you choose to use as the baseline from which your survival rate is calculated.
So, if we start right at the very beginning then at the point at which the mothers of the 66 babies who did survived to discharge were admitted to hospital because a problem had arisen their pregnancy then the survival rate based on the total number of foetuses that were still alive at that initial point of contact is just 11.1%. However, by the time we get to point at which they women who were carrying these foetuses actually went into labour then something close to 180 of the foetuses that had been alive at the point at which their mother had been admitted to hospital have already died and they’ll be excluded from any calculation which takes the onset of labour as the baseline from which the survival rates are calculated and already our survival rate is up to a bit of 15% even though the number of babies who actually survived to discharge hasn’t changed at all.
By the time we get to measuring the number of live births we’ve lost another 123 neonates, the ones that didn’t make through the birth itself and, on paper, our survival rate has jumped again, up to just over 19%, which is the figure that the Daily Mail cites as the EPICure 2 survival rate at 23 weeks (so at least we now know where that figure came from and what it actually relates to) and if we jump on again and take the number of babies admitted to a neonatal ICU as out baseline then we lose a few more babies from our calculation, the ones that sadly passed away in the delivery room within a matter of minutes of being born, and our survival rate has jumped again, only this time we’re now up to just over 30% as our “survival rate”.
Using the figures contained in the main EPICure 2 result paper we can continue that process through another two steps and two more baselines – whether that child was still alive at 7 days old and at 28 days old – and each time our survival rate improves but at no point in any of this has to the number of babies who actually survived to discharge altered once. There were 66 survivors when we started and there still still 66 survivors by the time we make our final calculation, even though that process has generated a total of six different survival rates just be moving the baseline.
What I’ve just illustrated, here, are two very simple statistical principles; you can only make sense of statistics given as rates or percentages if you know, or have been told, what the baseline is and you can only make a meaningful comparison between two set of statistics if both use the same baseline but these are both principles that newspapers routinely ignore and, of course, they’re principles that The Sunday Times has completely disregarded in putting this story together largely, it has to be said, because had it bothered to research the story properly then there almost certainly wouldn’t be a story, or at least not one that paper would consider to be worth printing.
So, having finally sorted all that out, where does it leave Nadine Dorries claim that if the NHS throws everything it has at a baby born at just 23 weeks gestation then that baby will have “an excellent chance of survival and an ongoing healthy life”?
Well, we’ve already seen that “an ongoing healthy life” is at best a highly questionable asserting given the very high rates of major morbidity in infants born at 23 weeks gestation and as for the “excellent chance of survival”… see for yourself as this next graph pulls together all the figures from EPICure 2 for admissions at 22-25 weeks gestation and shows the actual percentage survival rate for each gestational age at each critical stage from admission through to discharge from hospital. In short, this is the graph that women need to see if there’s a risk that they may go into labour earlier than 26 weeks gestation because it gives the complete picture of what your chances of actually leaving hospital at the end of it all with a live baby:
And I really do think that makes it very clear that if you and your foetus can hang on in there until 24 weeks or, better still, 25 weeks then it really does make a big difference both in terms of increasing the prospects of survival and reducing the risk of major morbidity.
After all that we need to get back to Nadine Dorries and to the fact that, in her article at least, she is not in the least bit interested in what the EPICure 2 study has to say about improvements survival rates for extreme pre-term births for the sake of those women who are unfortunate enough to go into labour at such an early stage in their pregnancy. All she’s really interested in here is whether or not she can sell these figures to the general public as an argument for a reduction in the current upper time limit for legal elective abortions and, to be honest, it really doesn’t matter that she’s been sold a bit of pup by the combined incompetence of The Sunday Times and Daily Mail because, let’s face it, factual accuracy has never really been her forte anyway.
The argument here is that we should set an upper time limit for elective abortions based on notions of foetal viability; that it is somehow wrong for us as a society to be allowing women to choose to terminate a pregnancy at a point where doctors are capable to saving the life of at least extreme pre-term infant born at the same gestational age, but is that really a good argument or just one that has no more a superficial plausibility?
The facts are that even with the best medical care the NHS has to offer, the odds that a women who goes into labour with a pregnancy at just 23 weeks gestation will end up leaving hospital, several months later, with a live baby, let alone a healthy baby are pretty slim – remember that graph deals on with mortality and survival, not morbidity where three quarter of all babies born at 23 weeks with have some sort of disability or long terms health problem and half will have a serious disability – and that’s looking at the question of viability from the entirely privileged position of women living in a Western industrial society with ready access to the best medical care.
Suppose, for a moment, that instead of looking at the evidence for survival rates amongst extreme pre-term infants in NHS hospitals this article had been about survival rates for extreme term infants born somewhere in, say, sub-Saharan Africa, in a country where for many, if not most, pregnant women the nearest clinic with just the most basic medical facilities can easily be a day or two’s walk from where they live and where the nearest neonatal ICU might as well be on the other side of Saturn for all they could ever afford its services. In that case, what kind of survival rates do you think we’d have been looking at and discussing?
At 23 weeks gestation, the answer is actually very simple – zero – and the same would be true at 24 weeks, 25 weeks, 26 weeks…
From what we know of infant mortality in the UK prior to the era of modern medicine and healthcare there’s a very slim chance that we might see our first survivors here at around 28-29 weeks gestation and even then we’re looking, at best, at odds of around 1 in 500 to 1 in 1,000.
That being the case, then we apply the logic behind Dorries’ viability argument to our hypothetical country in sub-Saharan Africa then it would be perfectly fine for that country to have a much higher upper limit for elective abortions than we have in the UK because the lack of access to medical care means that it’s only at around 28-29 weeks gestation that a pre-term infant has any prospect of survival.
That seems perfectly reasonable if viability is to be the basis on which we determine whether or not women can or cannot have an abortion and, actually, we can even take that argument a stage further because, of course, it’s not the case that poor countries in sub-Saharan Africa don’t have modern hospitals with modern neonatal care facilities. They do. But for most women living in those countries those services and facilities remain inaccessible because healthcare has to be paid for and the vast majority of women just don’t have the resources necessary to access the services provided by these hospitals.
So, again using viability as our guide, maybe we would be entirely justified in setting different abortion limits for different women depending entirely on whether they can afford to access the kind of healthcare necessary to give an extreme pre-term infant even a remote chance of survival; a lower limit for the rich minority of women who can afford the best healthcare services the country has to offer and a higher one for vast majority of women who can’t.
That seems perfectly fair, if viability is to be our guide to when it is, or isn’t, permissible for women to terminate a pregnancy.
Of course, I’m not seriously suggesting that we actually should do any of this, merely pointing out that the idea of using foetal viability as a basis for framing abortion laws and setting time limits on when women can, or can’t, access abortion services is not as straightforward as it’s proponents would have us believe and, of course, in all this the one crucially important thing that we haven’t touched upon at all is that somewhere in all this talk of foetuses and neonates and survival rates and viability there are living, breathing, thinking, feeling adult women attached to these foetuses that people like Nadine Dorries are so desperately concerned, women who might just like to have view on what can and cannot be done with, and to, their own bodies.
That might seem a bit of trivial to some people but, to me at least, that matters and it matters a hell of lot more than statistics and abstract moral arguments or Nadine Dorries’ bullshit.
I don’t personal profess to be a feminist. Never have done and probably never will do, but I am pro-choice and after writing easily over 100 mostly evidence-based articles on the subject of abortion over the last seven years and thinking long and hard I’ve come to very simple conclusion as to why I’m pro-choice…
…because women can think for themselves.
And that is as much of answer as I will ever need.