This opinion piece was published in 2008 to mark the 40th anniversary of the 1967 Abortion Act, which became law on 28th April 1968. It was published to accompany the passage of the Human Fertilisation and Embryology Bill through Parliament, as it was timely to reflect on what abortion legislation has meant for our specialty and our patients.
Hard facts about abortion in Britain before 1967 are few. Estimates of annual numbers varied from 14,600 (the figure given by the RCOG) to 100,000 (the Home Office estimate). In 1969, the first full year of the new law, 49,829 abortions were performed on residents of England and Wales, the total rising to 108,565 in 1972.
For the twelve years before the Act, abortion was the leading cause of maternal mortality in England and Wales. The first Confidential Enquiry into Maternal Deaths in 1952–54 reported 153 deaths from abortion, which was “procured ... by the woman herself in 58 instances.” The terminal event in 50% of illegal cases was sepsis but in 25% it was air embolus from “the injection under pressure of some fluid, nearly always soapy water, into the cervix or into the vagina.” The Report commented that most of the women were “mothers of families”. After 1968 maternal deaths from illegal abortion fell slowly but did not disappear until 1982.
Abortion numbers, however, rose steadily, helped by media “pill scares”, and reached 193,700 in 2006. The current British rates – 18.3/1000 in England and Wales and 12.4/1000 in Scotland – are similar to those in many Western European countries, but higher than those in Germany (7.6) and the Netherlands (6.5) and slightly lower than those in the USA (20.9) and Australia (19.7).
In 1973 34% of abortions in Britain were on women from abroad but this figure fell as laws changed across Europe. In 2006 there were 7,436 abortions to residents of other countries, mainly Northern Ireland (17%) and the Irish Republic (68%).
Among British women, the rate peaks at age 19 and falls sharply after age 24. Around 60% of women aged 20–24 use the pill and 13% now use long-acting progestogens but contraceptive use is highest among educated women and abortion rates are highest in deprived areas. The College is deeply concerned about the widespread closure of local family planning services and believes a rethink is needed in the way Sex and Relationship Education is provided in this country.
The rise in numbers over the last decade has been due to more abortions at <10 weeks. The total at 10–12 weeks has fallen and at >13 weeks remains steady, with 1.5% at 20 weeks and over. The upper limit has been 24 weeks since the HFEA Act of 1990. Responding to concerns about fetal awareness, the College assessed the scientific evidence and concluded that development of neural pathways necessary for awareness does not begin before 26 weeks’ gestation. Nevertheless at 22 weeks and beyond, abortion should now include feticide.
In June 2007 the Parliamentary Select Committee on Science and Technology set up an enquiry into scientific developments relating to the 1967 Act, including the 24 week limit, access to first trimester abortion and evidence on long-term health outcomes. The College will submit evidence to this enquiry.
In Britain, abortion is now safe for women, though still a distressing experience. Safe abortion is easily taken for granted and increasing numbers of trainees want nothing to do with this service. Conscientious objection is the right of every doctor but is a decision that needs careful consideration.
Nobody enjoys performing abortions. The doctors who do so are the ones who feel most strongly about reducing the need for abortion, and many work in difficult circumstances giving contraceptive advice to young women. They have the support of the College.