RCOG Guidelines

In January of 2011, the Britain's Royal College of Obstetrician's and Gynecologists published a draft document titled "The Care of Women requesting Induced Abortion: Evidence-Based Clinical Guideline Number 7" and requested peer review comments on the proposed guidelines.

After the period for submission of comments was closed, the draft document was removed from the internet. For the record, below are comments made by some reviewers.

The RCOG guidelines as published later are at this link.

Philip G. Ney MD DPM FRCP(C)

General

Theses guidelines are introduced by statements regarding the incidence of women "needing" abortion which are those who require this treatment to "prevent grave permanent injury to their physical or mental health" Since it is acknowledged this is very seldom to prevent permanent physical injury to the women, the authors can only be referring to permanent injury to a women's mental health. In effect these guidelines are asking Obstetrician/Gynecologist to form a prognosis of mental health for some time in the future without having any training to do so. They are required to act as a psychiatrist and prevent some disorder that even the most experienced psychiatrists hesitate to perform. This is not practicing evidence based medicine. The authoritative Comprehensive Handbook of Psychiatry states, "Psychiatric indications for abortion did not stand the test of scrutiny" "Women suffering from psychiatric illness before an abortion showed no significant improvement after abortion and had more difficulty coping with the stress of abortion than psychologically more healthy women."(1) The Canadian Psychiatric Association after reviewing the research issued this statement; "Justification of a decision to terminate a pregnancy under pseudo-psychiatric rubrics is to be deplored" (2) It must be concluded that since there are very few medical indications and no psychiatric ones, abortions are performed at the individual woman's choice. Not infrequently they are done when the spouse or family coerce a women with culture and convenience as the motives. Moreover the study with the best methodology to date (all pregnancy outcomes included for the women's entire reproductive history, valid measures, high level of agreement on estimates of health by patient, physician and independent assessor, representative sample, appropriate statistical analysis, found all types of pregnancy losses adversely affected a woman's generally health but that their health was significantly worse following an abortion. (3) It is indicative of the authors' bias that this study is not cited.

Prevalence

These guidelines assume the prevalence in the UK of women having an abortion is one third of all women by 45 years have had an abortion. They cite no evidence to support this statement. The prevalence rate is of vital importance because even if the harmful effects of abortion are "rare" there are such large numbers of women, that the overall impact on the nation's health is huge. For example if the rate of suicide is increased from abortion by those reported by the best studies (4,5) or even close there are such numbers of suicidal women, the psychiatric and forensic services of the UK will be overwhelmed. The authors are tacitly acknowledging there are no valid prevalence studies of abortion in the UK partly because the reporting of abortion is so bad. (6,) However in Denmark where aborting conditions are similar, the prevalence was 70% of women by 45 years in 1975. Assuming the prevalence has increased and the repeat abortion rate has at least doubled, Gynecologists must be very busy. They will naturally seek to implement time saving methods that are not in the women's best interests. If the adversely affected mental health rates have increased by anything close to the rates found by reputable researchers and published in peer reviewed journals (7,8) are even 50% off, (are there are no valid reasons to believe they are) there is huge number of new psychiatric patients. Psychiatrists are now so overwhelmed they have no choice but to resort to prescribing medication for every diagnosed illness whether or not they are caused by a "chemical imbalance". And if the mental health of other family members are at all affected by a woman's abortion (9) and there is considerable evidence to support this notion, there are even greater numbers of psychiatrically unwell people. So if for no other reason than the very badly underestimated prevalence of abortion in the UK, these guidelines are irrelevant.

Necessity

Not withstanding the GMC's recommendations to physicians to be kind to their patients, necessity is the first priority in any decision to treat. If any physician performs any procedure without a valid evidence based medical indication, it is common assault and can be prosecuted as such. This is seldom done because there is a collusion of silence between patient, government and abortionist. It is borne on the wings of engineered public opinion. Yet those who have terminated their practice of abortion say it very clearly, they were murdering children without cause. (10) If pregnancy is a disease requiring treatment by abortion it is also a self-limiting condition whose end is usually a happy occasion. If pregnancy were some condition that could cause or worsen a psychiatric condition then surely some form of psychotherapy would be tried first. As a wag in psychiatry once observed, "I really don't need a gynecologist to treat my patients if and when I fail". If this report was to deal with the facts, as every Ob/Gyn. knows them to be, there is seldom a legitimate reason to abort a woman's pregnancy. Even if there were such an indication, according to the dictates of every other area of medicine, some other less invasive and more reversible procedure would be tried first. It is argued here that an abortion is safer than a full term pregnancy. There is no evidence provided by this draft guideline. If it was so, and it is not after 13 weeks, the cause is surely time. With no evidence of embarrassment for this sophistry, the authors fail to acknowledge they are comparing an event which usually takes place at 6 to 8 wks of gestation with one at 38 to 40 weeks. Of course there will be higher rates of injury or mortality for an event that is 8 to 10 times longer on the basis of chance. It is like comparing accident rates between London and Brighton with those between London and Glasgow to indicate which road is safer. Yet with no evidence to support their contention, the authors write as a recommendation, 31 B. "Women should be advised that abortion is generally safer than continuing a pregnancy to term". Surely this sets the tone for the entire document. So the real "indication" is the woman's choice based on whether or not this preborn child is a planned pregnancy and "wanted". Even if that was an evidence based indication, every physician and parent is aware that wantedness is no kind of criteria for it varies from day to day depending on mood, finances, quality of relationship and amount of support. Moreover we found the amount of wantedness diminishes at the first trimester and then increases with the duration on the pregnancy (11) Some would even argue that overpopulation is an indication. Britons are painfully aware of the escalating economic problems arising from their low fertility rates. In essence, no country is able to run a free market economy with a declining population. As various nations become aware of this, they are urgently if not desperately trying to increase birth rates, usually with limited success.

Benefit

As no physician may perform any medical or surgical procedure without their patient have an authentic need for him/her to do so, so no physician may perform, recommend or refer for any treatment without substantial benefit there from. There is no evidence of benefit from abortion in approximately 95% of cases done for medical reasons and none what so ever supporting those done for psychiatric reasons. This is evident because if a couple really wants a preborn child, modern obstetrics will find a way. There is no evidence of psychiatric benefit because it is almost universally agreed that every psychiatric is made worse by abortion. The authors insist that the best evidence is provided by randomly assigned, double blind placebo controlled studies. No one has or could randomly assign abortion as treatment. So the next best evidence is supplied by longitudinal studies which when done show more evidence of harm than benefit. (12) This sad state of no evidence of benefit is made worse by the recommendation that Ob/Gyns have no need to follow-up their patients. In so doing they sidestep the most ancient control of medical practice, the evidence provided by the state of your patient's health in the long term. There is no study provided by any abortion provider to show benefit or harm on his/her own practice. So how can any of them assert they have do abortions in good faith? There are no serious attempts to show the benefits of abortion. Major's work, (13) purports to show that most women do not experience psychological problems but "negative emotions increased and decision satisfaction decreased over time". As part of the organization that provides the abortion, she collected data ½ hr before the procedure and shortly after. Considering the marked ambivalence and mental turmoil that many if not most women feel just before having the abortion, it is no wonder they feel relieved. Major's follow-up consisted of 50% of the sample, far too few to draw conclusions especially because those with the best results will continue in follow-up. In the long history of western medicine, it came to be understood that the burden of proof lays with those who provide, support and refer for any procedure to show beyond reasonable doubt that it is indicated, therapeutic and reasonably free from harm. This has not been done for abortion. To date there have not been serious attempts to meet these criteria.

Harm

The authors acknowledge there may be a range of emotional responses to the abortion but they make no mention of how intense or long lasting these may be. The evidence supporting recommendation # 34 are 3 articles none of which abide by the guidelines set by the authors for inclusion as recognizable research.. The evidence for supporting Recommendation # 40 is old and reviews the evidence for only one side of a seriously debated issue. Brind is cited only for his 1996 article and none since. The authors ignore the substantial evidence for the 300 to 600% increased risk of suicide including Gissler (13) and Reardon (14) even though both studies are of large samples, are record linked and published in reputable journals. Our study shows good evidence that women's general health is harmed by abortion but is not referred to. The tendency to select only that study which backs one's bias is disapproved in science, so why is it done so blatantly in these recommendations?

Conscientious Objection

It is recommended, # 7, in this draft that in spite of their ethical objections, physicians "have a duty to refer onward" Every evidenced base practice must apply good science to every patient for every procedure, when and if it is indicated, beneficial, relatively free of harmful effects, done with fully informed consent after careful examination and a specific recommendation, after other less invasive, more reversible therapies have been tried and failed, in good faith, (based on the physicians follow-up of his patients), and only after a 2nd opinion has been sought. Since none of these guiding constraints are applied to the current practice of abortion, no doctor is under any obligation to refer. In fact one can be held culpable if having made a referral to a physician who does not practice evidence based medicine, there is injury and suit. This is not a matter so much of conscience, as it is one of good practice. No physician can be forced to practice bad medicine no matter how politically expedient or popular or colleague approve. Yet these guidelines are attempting to do just that.

Summary

Although the authors of these guidelines insist on strictly good scientific evidence to support their recommendations, they do not adhere to their own principles. Consequently this report is full of bad science couched in scientifically impressive terms. It begins with a grossly under-estimated prevalence rate and continues to ignore any study that conflicts with it's bias. I have no doubt it will be accepted and by it those who do abortions will practice secure in the belief that they are good clinicians. Yet they may also have some kind of subliminal perception that all is not right. In growing numbers they stop performing abortions and if reflective wonder how they could go so far astray from their original hopes as a good physician. Is it with the uncomfortable sensation of a diminishing number of abortionists that the RCOG is seeking to bolster the practice of abortion and recruit more who will perform this damaging service to women. Was truth ever known in its time? Was there ever a profession which appreciated their authentic truth seekers? This is particularly a time when both the message regarding abortion and the messenger tend to be ignored or reviled. It will end because truth and gravity always win. As one who has treated approximately 2500 women and their families for psychiatric difficulties they attribute to an abortion and having done good research, I solemnly attest that if every scientific study found abortion harmless and beneficial, the testimonies of patients would confound them all. Are we not a clinical science? So then where is the evidence of harm spoken by patients recorded and responded to? I am convinced that if those who do abortions would listen carefully to all their patients and have them repeatedly return for follow up over a 10 year span, they would be persuaded they have done them no good.

References

Full list available on request.

1. Babikian HN, Abortion, In Comprhensive Handbook of Psychiatry, Kaplan HI, Freedman AM eds. 2nd Ed. 1496-1500, 1975.

2. Smith CM Can. Psychiatr Assoc Bull 13, 4, 23 Oct 1981.

3. Ney PG, Fung T, Wickett AR, The effects of pregnancy loss on women's health. Soc.Sci Med 1994;38:1193 -1200.

4. Gissler M, Hemminki E, Lonnqvist J, Suicides in Finland, 1987-94: register linkage study, BMJ,1996; 313: 1431- 1434.

5. Reardon DC, Ney PG, Scheuren F, Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J. 2002; 98: 834-41.

6. Brewer C, Huntington PJ, Mortality from abortion, The NHS record. Br Med J,1978; 2: 6136-562.

7. Reardon DC, Cougle JR, RueVM, Psychiatric admissions of low income women following abortion and childbirth. CMAJ 2003;13:1253-6.

8. Fergusson DM, Horwood LJ, Boden JM, Abortion and mental health disorders: evidence from a 30 year longitudinal study. Br J Psychiatry. 2008; 193: 444-51.

9. Ney PG Post abortion survivor syndrome (PASS): signs and symptoms. Southern Medical Journal 2006; 99: 1405 -6. and Ney PG, A consideration of abortion survivors Child Psychiatry and Human Development. 1983;13: 168-179.

10. Ney PG The Centurions Pathway. 2005, Victoria, Pioneer Pub.

11. Ney PG, Fung T, Wickett AR the Relationships between induced abortion and child abuse and neglect: four studies. Pre and Perinatal Psychology J.1993; 8: 43- 63.

12. Fergusson DM Horwood LJ, Boden JM, Reactions to abortion and subsequent mental health. Br. J Psychiatry; 2009 195: 420-6.

13. Major B, Cozzarelli C, Cooper ML, et al Psychological responses of women after first trimester abortion. Arch Gen Psychiatry, 2000; 57: 777-84.

Subsequent Comments Not Included in Peer Review Submission

The main issue is not that abortion is harmful.

The main issue is that this procedure has no indication, no medical justification and therefore it is criminal assault.

The second main issue is that there is no benefit.

The third is that it is not done in good faith.

The harm abortion does is about 6th in medical thinking.