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ACT Right to Life AssociationSUBMISSION |
Executive Summary
The draft report (the Report) prepared by a panel for the National Health and Medical Research Council (NHMRC) addresses a number of aspects of abortion provision in Australia.
The Report comes down resoundingly in favour of policies and actions which would promote the acceptance of abortion as a "normal" medical procedure of no particular significance. To this end the Report not surprisingly urges greater provision of abortion facilities, extension of counselling services for abortion, universal training in abortion techniques in medical and nursing schools, and the repeal of all abortion laws.
The ACT Right to Life Association objects to the Report in respect of its general approach to these issues and its particular recommendations:
The Association condemns the Report as a blatant attempt to force acceptance of abortion on the Australian community through increased spending on abortion facilities, counselling and training. This approach trivialises the significant sequelae of abortion and promotes the authors’ own agenda to repeal abortion laws. The Association asks the NHMRC to reject the Report.
Submission
The National Health and Medical Research Council (NHMRC) has released a review of abortion services in Australia and has invited comment on it. The draft consultation document is referred to in the covering note as the draft report (the Report).
The Report covers a wide range of matters related to abortion: provision of services, clinical methods, women's experience, contraception and the legal framework in which abortion is conducted in Australia.
The ACT Right to Life Association wishes to submit comments on the Report.
In each instance this submission briefly summarises the views expressed in the Report, paraphrases the relevant Recommendation(s) and offers a comment on the issue(s) involved.
Chapter 1 Services for termination of pregnancy
The Report notes the predominant reliance on the private sector to provide abortion services. It contrasts this with the "undersupply" in the public sector especially in rural areas where private clinical services for abortion would not be profitable. This, according to the Report, limits access to abortion for country women and affects the safety of the procedure by delay and the "potential emotional stress of continuing to carry a pregnancy which will be aborted".
Predominantly to blame for the lack of public provision of services, the Report claims, is the lack of a clear legal status for the procedure. The policies of regional health authorities and hospitals in relation to abortion are influenced by their interpretation of the legal and/or moral grounds for abortion. In South Australia and the Northern Territory, where abortion is regulated by statute, there is public hospital provision; in other areas the services are largely provided by private operators and public provision restricted to ‘medical’ abortion ie. abortions done on the grounds of the mother’s health or fetal abnormality.
Regional health authorities should enhance access to abortion by improving abortion facilities for rural women and for those women without private health insurance. These health authorities should provide abortion services as an integrated part of reproductive health care through private or public day-surgery units or through the ordinary hospital structure.
Clearly the provision of abortion services should be critically dependent on the legal status of abortion procedures. It is also obvious that individual practitioners and health/hospital authorities are obliged to take account of the current law in their jurisdiction. To assume otherwise, as the authors of the Report do, is to beg the questions posed by community debate concerning the current state of the law; it pre-empts and presumes the outcome of moves for abortion law change, whether these aim for de-criminalisation or legalisation on certain conditions set in statute.
Abortion procedures are not to be equated with other non-controversial procedures. It would be disingenuous not to expect that health providers when deciding on the provision of abortion services would be influenced by a complex of factors. Not least of these are the moral and ethical views of policy makers. It is notable that in every area of health provision other than reproductive services such considerations are presumed to be an essential part of the armoire of policy makers.
The relevant priorities to be afforded to competing demands for health services must also to be considered. Especially in rural areas there is a demand for better provision of many services eg oncology services and equipment to maintain patients with chronic renal disease. Affected patients are typically in need of these services repeatedly; lack of local access impacts very negatively on them and their families. By contrast, abortion is a single occasion procedure and can be arranged in centralised services. To assume that its provision in each area or region should be driven by the impetus of "choice" alone, without a proper ordering of competing priorities, is irresponsible and unrealistic.
The Report states that many abortion providers find their clients typically lack private insurance; moreover, because of concern to protect their privacy, some abortion patients fail to claim their Medicare rebates. The Report claims that abortion providers are inadequately recompensed by the prevailing Medicare rebates.
The level of remuneration for abortion services under the Medical Benefits Schedule be reviewed.
It is hard to reconcile this recommendation with the obvious profitability of abortion procedures for private providers. Surgical abortion is rarely provided in isolation from a battery of pathological tests and subsequent consultation for contraceptive advice and/or provision of the contraceptive or the fitting of an intra-uterine device. It is the totality of services delivered that makes the provision profitable to private operators.
The Report urges that abortion providers be sensitive to the cultural differences among women. It notes that, despite Medicare funding, many women are more concerned to protect their privacy than to claim their rebate; again some women resist counselling and intrusion into their emotional state.
The Report stresses the importance of information about abortion, especially telephone services which preserve anonymity. It praises the role of Children by Choice in Queensland which over twenty years has provided information and referral for abortion for nearly 100,000 women. By contrast it cites a study which criticises "false providers" of information which advertise as providing abortion counselling and support, but actually dissuade women from using abortion services.
Information about abortion should be included in community directories, at women’s and adolescent health centres, through Education Department counsellors, ethnic community organisations etc. State health authorities should ensure that suitable telephone services are available.
Ironically the Report shows its authors to be insensitive to cultural and religious differences in the Australian community. In discussing Aboriginal women’s health issues, the Report notes that because Aboriginal women have limited access to contraceptive choices, they have few alternatives to abortion. Despite this, the authors admit later in the Report that the abortion rate among Aboriginal women is low. It does not seem to occur to the authors that the alternative to abortion chosen by aboriginal women is clearly the birth of their children. The Report should direct its concerns to supporting the fertility choices of Aboriginal women with improved maternal and child health services.
The partial treatment of counselling providers is deplorable. The Report praises the work of the abortion referral group, Children by Choice. The activities of this organisation in booking women into Sydney abortion clinics, arranging group discount travel bookings and package deals has been well documented. Whether one regards this as desirable activity, it is unacceptable to praise their work while denigrating outlets which seek to dissuade women from abortion. If there are indeed providers of "false information", as alleged by the Report, they are exceptional among pregnancy counselling services. These services are professional in their approach and honest in stating that they do not refer for abortion. They provide women with a wide range of emotional and material support in pregnancy; it is often the case that no such help is offered by abortion counselling services and a balance is necessary.
The Report’s recommendation that abortion services should be universally touted throughout women’s and adolescent health services is to openly promote abortion as a legitimate birth control method. This insistence on the "normalisation" of abortion in health provision is a recurring theme throughout the Report. The Association rejects this approach completely.
Chapter 2 Clinical issues
The Report examines methods of abortion, optimum timing of the procedure, preferences for different methods and their complication rates. Complications are discussed: immediate ones like haemorrhage and uterine perforation, including uterine rupture in later term abortions through the use of prostaglandins; delayed effects such as infertility, future complications in pregnancy and birth; and associated risks like chlamydia infection, rhesus isoimmunisation, risk of breast cancer. Overall, the Report discounts the correlation between later complications and abortion.
The Report advises methods of reducing risk; it favours extraction over pharmacological methods in mid-trimester abortion, and promotes easier availability of drugs like RU486.
The Report overall attaches little significance to these various sequelae of abortion. Its references to the medical literature favours contributions from those known to be abortion providers. Its treatment of the sequelae trivialises the severe problems suffered by women in the short and long term.
Various aspects of this part of the Report are particularly revealing. It recommends that abortion of the foetus of over 16 weeks gestation be performed by the extraction method rather than by installation of pharmacological preparations. Reference is made to the preference of the staff and the woman for extraction, although it is more difficult for the practitioner. This is coy avoidance of the plain facts: installation and pharmacological methods result in the delivery of the foetus whole, well-formed and possibly alive. Dilatation and extraction involves the dismemberment of the unborn in utero and the results can be discarded in a bucket, thus avoiding confrontation by mother and staff with the real significance of the procedure.
The Report notes the "excellent" safety records experienced in non-hospital facilities in the USA and similar Australian data. It notes the recent tendency to develop free standing units with dedicated specifically trained staff to provide a "woman-centred supportive environment" for patients and staff. This specialisation is seen as promoting expertise and clinical skills.
The Report points out that hostility may be experienced from staff who do not approve of abortion when the service is mainstreamed in the hospital. Separate facilities avoid this but carry the disadvantage of ready identification of the facility by pro-life lobbyists.
The Report recommends free-standing specialised facilities where the case load ensures greater expertise.
This recommendation is hard to reconcile with the earlier recommendations that abortion should be easily available in rural area public facilities.
The Report quotes, apparently with approval, from a 1971 study to the effect that provision of abortion services is "an unavoidable responsibility of physicians and hospitals in rendering health care" to women. It is acknowledged that expert skills in procuring abortion are confined to a very few of the medical profession prepared to work in this area.
The Report considers that "the medical practitioner’s duty of care may reasonably be seen to extend to providing safe abortions for women seeking them, or at least facilitating access to sympathetic providers." (p.27)
The Report cites a 1993 USA report that the disincentives to do abortions are many: harassment for providers; relatively poor payment; professional isolation; few mainstream specialists and role models; absence of undergraduate and postgraduate programs in abortion practice.
The Report considers that the Royal Australian College of Obstetricians and Gynaecologists is responsible for ensuring the competence of its members in performing abortions. In fact, it complains, leadership and innovation in abortion provision has come from general practitioners specialising in abortion rather than from teaching hospitals and specialists in obstetrics and gynaecology.
Practical training in abortion procedures provided to general practitioners in hospitals and clinics should be standardised and recognised. Further the RCOG and RCOGP should in association with the Abortion Providers Federation of Australia adopt leadership roles in teaching abortion techniques. The Colleges should ensure training of their members in hospital and community programs. Also university Departments of Nursing Education should integrate abortion within their reproductive health curricula.
These recommendations touching the training of personnel for abortion provision are a naked attempt further to "normalise" the procedure itself and to strip it of significance for those who seek it and those who might provide it.
The Report wishes to implicate top professional and academic bodies in promoting abortion provision. The authors comment that the confinement of abortion skills to a very few of the medical profession "needs to be reversed". Once again the Report is attempting to dictate an outcome to those intimately involved in this debatable issue. Only grudging acknowledgment is given to the fact that "the moral aspects of termination of pregnancy allow practitioners to choose not to be involved". (p.27)
It is special pleading to argue that the Colleges of obstetricians and gynaecologists and of general practitioners should promote training in induced abortion methods. Practice obtained in dealing with incomplete spontaneous abortions and with therapeutic curettage has not in the past proved inadequate preparation for the practice of obstetrics and/or gynaecology either by the general practitioner or the specialist. Training in procuring abortion is intended to be training for procuring abortion.
The approach of the authors is another clumsy attempt to "normalise" the practice. The authors unwittingly admit the unique nature of abortion procedures. Pertinent here is the discussion in the Appendix of the medical advantages of D and E for second trimester abortion. In this connection the authors comment that the operating surgeon must be "emotionally robust"! The ordinary person might think "callous" the more appropriate word as the dismemberment of a large fetus is the procedure under discussion.
If these recommendations were adopted the result would be the virtual elimination from the medical and nursing professions those candidates with a moral objection to the practice of elective abortion in the absence of threat to the mother’s life.
These recommendations are patently an attempt to promote abortion by both begging the question of its moral and legal status and by restricting the freedom of medical and nursing staff to dissent from the pro-abortion lobby.
Chapter 3 The Experience of Abortion
The Report presents conflicting evidence as to women’s feelings about abortion. On the one hand, studies are cited to the effect that induced abortion does not have harmful psychological consequences. On the other hand, the Report admits that methodological faults have been found in most studies of psychological and psychiatric sequelae of abortion.
A number of studies show factors likely to result in poor emotional outcomes from abortion: coercion; abortion on medical or fetal indications; lack of sympathy from family or staff; an environment which regards abortion as criminal; women with personal problems and religious or cultural attitudes opposed to abortion.
The Report claims that implications for best practice include: the need to validate the woman’s feelings; provision of support and information without coercion or influence; provision of special care for women having abortions on medical grounds or because of foetal abnormality; sympathetic and sensitive treatment of abortees; resort to other specialised support for victims of sexual violence.
It claims that women are negatively affected by the illegality, perceived or real, of abortion.
The Report asserts that it is essential for counsellors not to present abortion as a problem. Disapproval may also compromise the woman's well-being. The woman's decision is to be supported; it should not be influenced nor subverted. The authors complain again that the woman's autonomy is constrained by legal requirements.
Studies of the effect of abortion denied are included. One study shows only a small proportion of such women adopt away the child after its birth.
Abortion service providers including counselling and referral agencies should emphasise and support the woman’s own role in deciding.
The emphasis throughout this part of the Report is on process:
"... the decision-making process is central to a healthy outcome ... it is desirable to ensure that practice by health care providers is based on respect for the woman’s autonomy to make decisions, and is designed to support the woman's decision ..." (p.33)
The substance and significance of the decision are ignored. In a recent article Naomi Wolf, noted feminist author and advocate of the "pro-choice" position on abortion takes issue with this very approach. She now finds the language of "choice" and "decision" limiting in promoting understanding of what is at stake:
"Pro-choice advocates tend to cast an abortion as ‘an intensely personal decision’. To which we say, no: one’s choice of carpet is an intensely personal decision. One’s struggle with a life-and-death issue must be understood as a matter of personal conscience. There is a world of difference between the two, and it's the difference a moral frame makes." (The Australian, 7-8 October 1995)
Put another way, counselling in this area presents moral dilemmas which must be resolved. Yet the Report is anxious to remove from the counsellor’s practice any consideration of the legal and/or ethical implications of the procedure being considered. This is completely unrealistic. The Report's constant emphasis on the need to support the woman’s decision is hollow and vitiates intelligent discussion both of the content of the decision to be made and the obligations of counsellors.
The Report uncritically accepts various criteria for best practice in counselling for abortion. One such criterion describes as "unsympathetic or punitive" allowing the screen to be visible to the patient when the gestational age of the foetus is being ascertained through ultrasound imaging. The woman is to be shielded from the "possible emotional power of the images produced".(p.32) In other words, the sight of her unborn child would be critical input into the information the woman surely needs to make an informed decision about its fate. This censorship in fact denies the woman’s right to autonomy.
The Report condemns itself by approving such manipulation. The Report underlines its bias further: such ‘sympathetic’ abortion counsellors are approved while the report castigates the alleged ‘false information’ provided by some pregnancy support services (the actual content of this ‘false information’ is not specified).
The Report prefers those agencies which offer women ‘counselling’ in an ethical vacuum so as not to upset an option for abortion. To achieve this outcome they are prepared to deprive women of vital information concerning the unborn child’s development.
The low proportion of women denied abortion who subsequently adopt away their child is a provocative datum which the Report does not analyse. It could be evidence that a woman's feelings about her pregnancy at a particular point are not a good predictor of how the woman will feel about the child at term. It also might indicate that the grounds advanced for the majority of abortions are passing matters which do not threaten the mental or physical health of the pregnant women; nor in the long run are their lives demonstrably disadvantaged for not having been given an abortion.
The Report complains that the non-judgemental role of providers is complicated by the "legally mandated gate-keeping function" imposed on them. In addition some practitioners appear to depend on their personal views in judging the legality of an abortion. Consequently women are forced to present their request for abortion in terms the doctor considers valid. Consequently the "counselling enterprise" is conducted with tension between supporting a woman's decision and meeting legal requirements.
The Report considers that counselling should not be mandatory. Counsellors should refrain from imposing their own sexual and moral standards.
Information about alternatives is essential. Also information about the details of the abortion should be routinely provided; such information is essential for informed consent.
Counselling should be provided both as part of, and separate from abortion services. It should be available to all women, but should not be compulsory.
The Report stresses that "adequate information is essential for informed consent" and refers to the Council’s own guidelines for medical practitioners. This is oddly inconsistent, as pointed our above, with the authors’ accepting the "best practice" of hiding visual information about the foetus from the mother. The Report narrowly conceives ‘information’ exclusively as details about abortion procedures.
The Report acknowledges that hospital staff may be unwilling recruits for abortion services and that Australian experience indicates that the formation of specific units within hospitals is warranted. Staff in such units need a supportive working environment with access to appropriate counselling and perhaps the explicit hospital policy support for the service. They may also need protection from harassment.
Board or senior level support of hospitals providing abortion should demonstrate support for the service. They should also provide professional support to staff working in abortion units. Staff should be protected from harassment at work, and if possible at home or in the community.
These recommendations starkly reveal the problematic status of induced abortion. Staff in general hospitals are admittedly reluctant to undertake the work. The only nostrum being prescribed is to spread the work whether staff wish to be involved or not, and to demand a "supportive environment". It is unrealistic to demand that medical and nursing staff react to abortion procedures in as detached fashion as they might deal with a perforated appendix. The recommended provision of elaborate counselling support for staff engaged in the procedure is presumably to be procured a the expense of other medical resources. These recommendations are patently attempts to impose ‘political correctness’ as interpreted by the pro-abortion lobby on those responsible for health policy and provision.
Chapter 4 The question of prevention
The Report is concerned to maintain a "continuing place for abortion within control strategies." It comments that abortion will always be necessary for a number of reasons which include: inability to control, or even unwillingness to acknowledge fertility, especially among the young; the ineffectiveness of contraception for some women; violence against women; the reluctance of Australian men to accept responsibility for fertility control; changing social circumstances after pregnancy has commenced.
The Report provides various statistics on the incidence of unintended pregnancy (of very problematic accuracy); the proportion of live births to abortions in Australia; a comparison of abortion rates among different countries. The authors make the dubious claim that abortion rates have fallen markedly since the 1930’s; also problematic is the estimate that 30% of all Australian women have had abortions.
Other significant statistics address the characteristics of women who seek abortions:
The Report admits that education for ‘safe sex’ practices does not necessarily lead to effective use of contraception. Nonetheless the authors are confident that education in this area will assist in reducing the rate of unintended pregnancies. They also call for more attention to "post-coital contraception" and say that only 10% of women knew how to obtain and only 3% used it. The Report proposes that consideration should be given to allowing access to an emergency contraceptive pack without prescription
The Report states that there will be a continuing need for abortion services in the second trimester of pregnancy. However, the authors argue that increased information about, and availability of and community acceptance of abortion will reduce the incidence of these late abortions.
The authors report that an inevitable rise in the number of women having repeat abortions is inevitable after legalisation and the increase is predicted to continue until the end of the century. They warn against "punitive" approaches to such women.
The authors recommend that abortion referral services be accepted as part of a comprehensive fertility strategy in Australia.
The Association has no official stance on the matter of prevention of pregnancy. It is, of course, opposed to those methods of birth control which do not prevent conception, but rather cause the destruction of the life of the conceptus whatever its stage of development.
These recommendations concern the provision of contraceptive services. Abortion is again advanced as necessary to compensate for failed contraception or the failure to use contraception.
The Association is concerned that the agenda pressed by the Report for the intensification of ‘safe sex’ education offers no ethical perspective on abortion. Its advocacy of these services openly advances a defence of abortion as a necessary backstop for neglected contraception or because of the inherent failure rate of contraceptive methods. Responsibility for one’s actions is not explored; the message is clear that abortion should be available simply because a woman has failed to use contraception, used it incorrectly, or because the method has failed.
This part of the Report underscores clearly the difficulty faced in responding to the Report if one does not share its presumptions that there are no legal requirements nor ethical parameters governing the provision of abortion.
Chapter 5 Legal framework for abortion services
The authors complain that alone among medical procedures abortion is regulated through the criminal law; this regulation acts as a "gatekeeping" mechanism which allegedly intrudes adversely on the overall health care offered to women. The solution offered, predictably, is the repeal of criminal law provisions pertaining to abortion and the regulation of abortion through the existing legal, professional and administrative management of the health system and medical practice. The Report recommends that even the restriction of abortion procedures involving viable fetuses should simply be controlled through medical and nursing Boards in each State.
That routine data on abortion be collected as part of existing pregnancy outcome data collections.
This recommendation is vacuous and only marginally related to the sweeping approach to the repeal of the criminal code which precedes it. There is no current barrier to the collection of abortion statistics.
This part of the report underscores clearly the difficulty faced in responding to it if one does not share its authors' presumptions and ethical position on abortion. Overall, the Report is an apologia for unrestricted access to abortion. To this end, expensive, widespread provision of abortion services, significant changes to medical and nursing training, and radical changes to legislation are demanded in defiance of the complex issues these proposals involve.
Contemporary abortion methods
The Report includes an Appendix on contemporary abortion methods. There are no specific recommendations growing out of this part. The authors, however, emphasise throughout the alleged safety of abortion done by qualified practitioners. Despite this assertion, there are alarming inconsistencies in the data presented and the claims put forward.
On the one hand, it is asserted that the rate of abortions to births is not affected by the legal status of the procedure: all that is at stake is the safety of the procedure. Yet the proportion of maternal deaths due to abortion in Australia has altered very little over 60 years. Perhaps the performance of abortion almost exclusively by qualified practitioners (which the Report says is the case in Australia) has not improved the safety of the procedure. If this appears absurd, then the better explanation might be that estimates of abortions performed before the liberalisation of its provisions in the 1970's are grossly exaggerated. These exaggerations are advanced to convince a gullible community that legalisation/liberalisation does not increase the abortion rate.
A sensible reading of recent developments is that the abortion rate has increased markedly; therefore, although the procedure is safer as it is provided by medical practitioners, more women are exposed to the attendant risks of mortality and morbidity.
The Report sets out the complications of abortion, both immediate and delayed, for different gestational ages and different methods. They are sufficiently alarming eg. the chances of uterine haemorrhage and perforation and pelvic sepsis, that it should be mandatory that these statistics be given to all women seeking abortion. Bland reassurance that abortion is a safe procedure when performed by qualified medical personnel is contradicted by the figures themselves.
The authors admit that longer complications are significantly under-reported. Yet, the Report attempts to diminish the significance of such sequelae, arguing that later problems in pregnancy are not exclusively associated with prior experience of abortion. Difficulty in becoming pregnant after abortion is discounted as "inadequately studied". This, despite frequent statements of those operating in in vitro fertilisation (IVF) programs that a significant proportion of their patients have fertility problems because of previous abortion(s).
Currently there is a growing demand that patients give informed consent to treatment. Recent litigation has demonstrated that even remote chances of injury from a procedure must be explained to the patient. Yet the Report throughout is deliberately selective in recommending what information the woman contemplating abortion should receive: the woman is to be sheltered from seeing ultrasound images of the baby in utero; the complications set out in the Appendix may not be provided by abortion counselling services.
Further reading
Angelo, EJ, (1992) Psychiatric Sequelae of Abortion: The Many Faces of Post-Abortion Grief. Linacre Quarterly, Vol.59(2), May, pp69-80.
Davis, A, (1987) Women with disabilities: abortion and liberation. Disability, Handicap and Society. Vol. 2(3), pp 275-284.
De Veber, LL, Ajzenstat, J, and Chisholm, D, (1991) Post-Abortion Grief: Psychological Sequelae of Induced Abortion. Humane Medicine, Vol. 7(3), pp 203-209.
Fisher, A and Buckingham, J, (1985) Abortion in Australia: Answers and Alternatives. Dove Communications, Melbourne.
Mathewes-Green, F, (1991) Unplanned Parenthood: Easing the Pain of Crisis Pregnancy. Policy Review, No.57, Summer, pp 28-36.
Ney, PG and Wickett, AR, (1989) Mental Health and Abortion: Review and Analysis. Psychiatr J Univ Ottawa, Vol. 14(4), pp 506-516.
O’Donovan, M and Stuparich, J (eds), (1994) The Abortion Debate: Pro-Life Essays. ACT Right to Life Association, Canberra.
Overduin, D Ch, (1991) Abortion in South Australia 1970-1990: Data, Observations and Conclusions. DBI Study Booklet No.16, Dietrich Bonhoeffer International Institute for Bioethical Studies, Adelaide.
Schmidt, J (ed), (1990) To the Unborn with Love: Essays in Honour of Daniel Ch Overduin. Lutheran Publishing House, Adelaide.
Speckhard, AC and Rue, VM, (1992) Post-Abortion Syndrome: An Emerging Public Health Concern. Journal of Social Issues, Vol.48(3), pp 95-119.
Wilks, J, (1994) Death in a Drug: The Facts, Fallacies and Philosophy of RU-486. Foundation for Human Development, Sydney.
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