bpas briefing: Abortion Providers and Pregnancy Advice

This briefing intends to address some of the principal concerns raised by the Dorries/Field amendments to the Health and Social Care Bill, so that debate around this issue is properly informed.

In March 2011, Nadine Dorries MP and Frank Field MP tabled amendments to the Health and Social Care Bill, dealing with the provision of pregnancy advice and counselling for women considering an abortion. The Bill is due to be debated in autumn 2011. It has also been suggested that the Department of Health may change their own regulations to put the substance of these amendments into practice, without having the debate in Parliament.

British Pregnancy Advisory Service (bpas) is concerned that these amendments represent a misunderstanding of the way that abortion advice and counselling is currently provided in England and Wales, and the reasons why provision has evolved in the form that it has.

What does the Dorries/Field amendment seek to change?

The amendment’s main proposals are:

• That the National Institute for Clinical Excellence (NICE) must ‘make recommendations with regard to the care of women seeking an induced termination of pregnancy’, with which abortion providers must comply.

These amendments, if passed, would require a significant reorganisation of current services. The Department of Health notes that currently, ‘women may obtain advice on pregnancy matters and access to abortion services through a GP, NHS clinic/hospital, or PAB [Pregnancy Advisory Bureau]’. Pregnancy Advisory Bureaux (PABx) are registered by the Department of Health, and have to comply with a stringent set of Required Standard Operation Principles (RSOPs), which are available to read here. A list of registered PABx is available here.

The regulations note that ‘All premises seeking approval as a PAB will be required to confirm that they will comply with a core set of principles, known as “Required Standard Operating Principles – RSOPs)”. In particular, every woman must:

The existing RSOPs state that ‘Clinical practice and good quality care should be guided by authoritative clinical guidelines and professional opinion such as that provided by relevant Royal Colleges.’ The Royal College of Obstetricians and Gynaecologists (RCOG) regularly reviews its thorough evidence-based guideline, The Care of Women Requesting Induced Abortion, the most recent version of which is due to be published; guidance from the Royal College of Anaesthetists and the Royal College of Nursing is also followed.

The Dorries/Field amendment appears not to recognise the standard of professional guidance that already informs clinical practice in abortion services. Unless there is a concern that these professional bodies are somehow lacking in expertise, it is hard to see any argument for transferring clinical ‘recommendations with regard to the care of women seeking an induced termination of pregnancy’ to NICE.

As to the provision of information, advice and counselling, the arguments put forward by Dorries and Field for transferring this role to an ‘independent provider’ implies that organisations, such as bpas, which provide both pregnancy counselling and abortion have a ‘conflict of interest’ or a ‘vested interest’ in women having abortions, as they also receive payment for providing treatment.
The implication of these amendments is that women are therefore being pushed towards having abortions that they do not want. This argument is reviewed below.

Do abortion providers have a ‘vested interest’ in women having abortions?

bpas, as a charity, provides both pregnancy consultation and abortion treatment. These are conceptualised, and funded, as completely separate areas of care. The vast majority of bpas’ clients (over 93%) are funded by the NHS. Where funding for consultation is provided this is not linked to whether or not an abortion subsequently takes place, and bpas offers every woman as many consultation appointments as she wants and needs.

At bpas, approximately one in six women who come for a consultation do not proceed to treatment It is not known if more women who attend consultation appointments and receive counselling with abortion providers choose abortion than women using other services. There are no national statistics on this: the Department of Health only collects statistics on the number of abortions that have been provided, not the number of consultations that have taken place.

The Dorries/Field amendment presumes that a problem exists with pregnancy counselling, but have not said what this problem is, or what evidence there is at all that a problem exists with the current situation.

It is also important to note that, in line with Department of Health regulations, bpas also provides contraceptive counselling and, where the NHS contract allows it, prescriptions for oral contraception or the fitting of Long-Acting Reversible Contraceptives (LARCs) such as the implant or coil. The charity offers a vasectomy service, and screening and treatment for sexually-transmitted infections.

As a charity committed to reproductive choice, bpas aims to enable women to avoid unwanted pregnancy through contraception, and to protect their future fertility through treatment for STIs. Providing a safe and sensitive abortion service is key part of what the charity does, but its commitment is to reproductive choice. To imply that bpas has a ‘vested interest’ in rushing women to have abortions they do not want is both inaccurate and a slur on the commitment of bpas’s staff to the women in their care.

What does ‘information, advice and counselling’ about pregnancy currently involve?

The Dorries/Field amendments imply that ‘information, advice and counselling’ about pregnancy are all the same thing. In fact, since the implementation of the 1967 Abortion Act, good practice has developed around each of these aspects of abortion care.

Briefly summarised, advice in the context of a pregnancy options discussion relates to a woman’s options when experiencing an unintended or unwanted pregnancy. These options are abortion (depending on the gestation of the pregnancy), adoption, or continuing the pregnancy to term. All registered Pregnancy Advisory Bureaux comply with the Department of Health’s requirement to make available ‘literature and information on alternatives to abortion – for instance adoption and motherhood – from sources independent of the PAB for women who decide to continue with the pregnancy.’

Counselling is a term that should be used carefully, as it can mean different things in different circumstances. Current Department of Health regulations of Pregnancy Advisory Bureaux, as with the bpas protocol, state that make it clear that counselling is distinct from the general pregnancy options discussion that all women have.

bpas’ clinical protocol, published in 2009, states:

‘Clients attending bpas centres will have varying needs from a Pregnancy Options Discussion. Many clients will have already made a decision to have an abortion, but may still need a supportive listener who will advocate for their needs while they access our services. Some clients will be uncertain as to whether or not they will continue their pregnancy, and may need to spend more time discussing their situation and feelings. A small number of clients will need structured counselling to address more complex issues. These clients should be recognised and referred appropriately. The Pregnancy Options Discussion should therefore be tailored to the needs of individual clients.’

The DH regulations state that ‘Counselling must be offered to women who request or who appear to need help in deciding on the management of pregnancy or who are having difficulty in coping emotionally’, and that it should also be offered ‘to women under 16 and to those with a history of psychiatric illness, who lack social or emotional support or whom their partner, family or employer is
possibly coercing into having an abortion.’

The regulations further state:

‘All staff must realise that a woman may not resolve ambivalence about a pregnancy during a counselling session. Rather, the session helps her clarify her thoughts and facilitates constructive discussion during the next few hours or days. This is often through more effective communication with her partner or some other person who is emotionally close. Women who remain ambivalent after counselling can be given a provisional appointment for admission but must be told that the procedure can be postponed or cancelled and that she remains free to continue with the pregnancy if, on reflection, she decides this would be the most satisfactory outcome.’

The information offered to women at consultation follows the RCOG’s guidance. It pertains to the relative risks of abortion and the different methods of abortion (medical or surgical) offered by the clinic. bpas is committed to offering women a choice of method, and for women who decide to have an abortion, this is an important component of the discussion.

Why do abortion providers conduct pregnancy options discussions, rather than ‘independent providers’?

An increasing proportion of NHS-funded abortion care is carried out by bpas and other organisations in the independent sector. This reflects policymakers’ view that abortion, as a legally-available treatment, should be publicly funded as are other areas of healthcare; along with a recognition that dedicated independent providers are able to provide a specialist, sensitive service that can work as well if not better than services run by NHS hospitals.

As Dr Ellie Lee, Reader in Social Policy at the University of Kent and author of Abortion, Motherhood and Mental Health, explains, in her literature review of pregnancy advice and counselling, there is a long history behind the development of pregnancy counselling as an aspect of abortion care. The main points that emerge from this history is that the relationship that evolved between Pregnancy Advisory Bureaux and abortion clinics was generally considered to be a positive one, as it allowed women access to a range of specialist medical professionals who could interact with one another.

The Department of Health’s RSOPs explain this interaction as follows:

‘Medical staff who attend PABx may have relatively little experience of surgical abortion requirements whilst highly experienced specialist gynaecologists may have relatively little experience of assessment. In view of the close working relationships which often exists between PABx and many clinics and the benefits that will be brought to the care of women, it is recommended that close contact and regular exchanges are maintained between medical staff working in the different settings.’

A care pathway has developed that could build in the importance of a pregnancy options discussion without putting barriers in the way of those women who are sure about their abortion decision. This is a crucial consideration for abortion services: abortion is a procedure that has to be carried out within a specific time-frame (before 24 weeks, apart from exceptional cases), and is safer and more acceptable the earlier in gestation that it takes place.

The existing regulations recognise that delay before treatment is sometimes necessary: when a woman is ambivalent about her decision and needs more time to make up her mind. But when delays are unnecessary, forcing women to wait before they act on their decision is punitive and clinically unsound.

What ‘independent’ pregnancy advice services currently exist?

It is unclear from the Dorries/Field amendment what kind of ‘independent’ services are being proposed. Currently, only registered PABx can refer for abortion treatment (outside of GPs and NHS clinics or hospitals), and for the reasons discussed above, most of these are linked to services that also provide abortions. To develop a ‘statutory’ body that provides pregnancy advice would be an enormous undertaking for the health service, particularly in the current economic climate.

The other pregnancy advisory organisations currently in existence are those that are generally connected with the organisations LIFE or Care, which oppose abortion on principle. Many of the ‘crisis pregnancy centres’ affiliated to Care Confidential are connected to local churches, and staffed by volunteers.

One concern about these crisis pregnancy centres is the extent to which they are influenced by a particular perspective - religious or otherwise - that may affect the impartiality of advice offered to those women seeking help. Another concern is that, because women visiting these organisations may not be aware that they cannot refer for abortion (as they are not registered with the Department of Health), unnecessary delays are introduced for women who have made their abortion decision.

Conclusion

This briefing has aimed to clarify the process of pregnancy advice and counselling that already takes place in Britain. It indicates that women’s need for time to consider their decision has been long established as a principle in abortion consultation, and that nobody’s interests lie in rushing women through the process.

Abortion providers such as bpas can only work to address any problems perceived to exist with service if they know what the problems are perceived to be. In the current debate it is unclear what problems are thought to exist, since no issues have been raised with those currently responsible for abortion counselling and referral.

Also read:

UK: Controversy over pregnancy counselling. Abortion Review, 29 June 2011

Pregnancy counselling in Britain: a review of the literature. By Dr Ellie Lee. Abortion Review, 29 June 2011

Source: http://www.abortionreview.org