Seven days in medicine: 25-31 March 2020BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1288 (Published 02 April 2020) Cite this as: BMJ 2020;369:m1288
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Home medical abortions
It is a concern that the Government has allowed the introduction of home medical abortions without Parliamentary scrutiny in the middle of the catastrophic Covid 19 national emergency. Despite Department of Health reassurances that medical abortions are safe, the medical evidence does not support this.
Medical abortion is now the preferred method to terminate a pregnancy in the UK (1). National statistics from 2018 (the latest available) show that 71% of induced abortions were medical. The percentage of medical abortions has steadily increased from 39% in 2008.
There is a significant complication rate of medical abortion. A Finnish study from 2011 (2), looking at the outcomes of medical abortion in 27,030 women found a rate of surgical intervention for haemorrhage of 10.7% following medical abortion. This was the same for younger and older women.
An earlier Finnish study from 2009 (3) looked at complication rates after first trimester abortions in 47,000 women and found that six weeks after an abortion the incidence of complications after medical abortion was four times higher than surgical ones – 20% compared to 5.6%.
The Royal College of Obstetricians and Gynaecologists’ 2011 guidelines on termination of pregnancy (4) found complication rates between 2.5% and 53% in medical abortions. Another Finnish study from 2014 (5) found a 51% surgical intervention rate after medical termination of pregnancy.
The importance of the rate of surgical intervention is that it is a major risk factor for premature birth in subsequent pregnancies. There have been three systematic reviews of this. One review (6) found that a single surgical abortion increases the risk of subsequent premature birth 1.38 times while two surgical abortions more than double the risk for subsequent premature birth. Premature delivery brings with it a whole host of complications for the baby.
Women have a right to know about these complications and to be counselled for the risk of surgical intervention and subsequent premature delivery when they consent to a medical abortion. It is a derogation of good medical care of women when they are handed two tablets to terminate a pregnancy at home and then left on their own to deal with the complications.
2. Niinimäki M, Suhonen S, Mentula M, Hemminki E, Heikinheimo O, Gissler M. Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: population register based study. BMJ 2011;342:d2111. (19 April.) Abstract/FREE Full Text
3. Immediate complications after medical compared with surgical termination of pregnancy. Niinimäki M1, Pouta A, Bloigu A, Gissler M, Hemminki E, Suhonen S, Heikinheimo O.
Obstet Gynecol. 2009 Oct;114(4):795-804. doi: 10.1097/AOG.0b013e3181b5ccf9.
4. Care of women requesting induced abortions. Revised edition Nov 2011. Royal College of Obstetricians and Gynaecologists. London.
5. Contraception. 2014 Feb;89(2):109-15. doi: 10.1016/j.contraception.2013.10.015. Epub 2013 Nov 6. Medical termination of pregnancy during the second versus the first trimester and its effects on subsequent pregnancy. Männistö J, Mentula M, Bloigu A, Gissler M, Niinimäki M, Heikinheimo O.
6. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analyses. Shah P, Zao J on behalf of Knowledge Synthesis Group of Determinants of Preterm/LBW Births. BJOG 2009; 116:1425-1442. DOI: 10.1111/j.1471-0528.2009.02278.x.
Ian B Johnston
Specialty Doctor in Community Paediatrics
Croydon Health Services NHS Trust
12 - 18 Lennard Road
Croydon, Surrey CR9 2RS
Competing interests: No competing interests
The sad news (at the time of writing) that four doctors working in the NHS have died of Covid-19 is aggravated by the fear that these may be the 'tip of the iceberg' including nurses and other health care workers, as well as social care or other workers, who may yet succumb in the course of this terrible epidemic. Undoubtedly these fatalities will engender speculation as to whether, or to what extent, occupational exposure may have been responsible for an increase in the risk of contracting Covid-19 and of dying from it. In due course occupational epidemiologic research should give us some of the answers at a 'population' level.
But what about these workers as individuals? What specific circumstances might have contributed to their deaths? Doctors are reminded that there is a legally mandated mechanism that may help answer these questions. Under UK law, doctors have a legal duty to notify a senior coroner of a death if "the registered medical practitioner suspects that the person’s death was due to ... disease attributable to any employment held by the person" [ http://www.legislation.gov.uk/uksi/2019/1112/made ]. As the statutory instrument makes clear, the obligation to notify HM coroner is triggered by a mere suspicion on behalf of the notifying doctor.
After notification, the coroner would consider whether an inquest is warranted, and during this relevant witnesses can be summoned to be questioned and to testify under oath. Notification to the coroner should not be viewed by doctors merely as a legal obligation. It is more than that. The coroner is entitled to make 'Reports on Action to Prevent Future Deaths'.
Competing interests: No competing interests