The law and epidemiology of induced abortion

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B (alone, or with C or D)
C (alone)
D (alone, or with C)
E (alone, or with A, B, C or D)

61
130
180,117
2,122
2,692 14
81
141,644
1,605
20 9
21
24,257
431
366 21
18
12,259
85
1,431 17
10
1,957
1
875 Total 185,122 143,364 25,084 13,814 2,860

The HSA4 form allows the recording of all medical conditions and other details associated with the ground, such as the method used to make the diagnosis. In previous years, only the principal medical condition was published. Table 18.2 shows totals for the number of mentions of a medical condition in 2012. For example, congenital malformations were mentioned 1,676 times within the 2,692 Ground E cases, although they were cited as the principal condition in 1,197 cases[23].

Table 18.2 Legal abortions: principal medical condition and total mentions of medical conditions for abortions performed under Ground E, residents of England and Wales in 2012[23]

England and Wales, residents				Numbers and percentages^b
ICD-10 code	Condition^a	Number of abortions by principal medical condition		Number of mentions by principal medical condition		Over 24 weeks’ gestation
ICD-10 code	Condition^a	Number	%	Number	%	Number	%
Total ground	E alone or with any other^c	2,692	100			160	100
Q00–Q89	Congenital malformations total	1,197	44	1,676	49	106	66
Q00–Q07	Nervous system total	607	23	755	22	69	43
Q00	Anencephaly	208	8	216	6	5	3
Q01	Encephalocele	33	1	39	1	1	1
Q02	Microcephaly	6	0	13	0	4	3
Q03	Hydrocephalus	26	1	36	1	3	2
Q04	Other malformations of the brain	109	4	156	5	30	19
Q05	Spina bifida	149	6	167	5	5	3
Q06–O07	Other	76	3	128	4	21	13
Q10–Q18	Eye, ear, face and neck	2	0	2	0	0	0
Q20–Q28	Cardiovascular system	191	7	305	9	12	8
G30–Q34	Respiratory system	16	1	26	1	1	1
Q35–Q37	Cleft lip and cleft palate	4	0	12	0	0	0
Q38–Q45	Other malformations of the digestive system	6	0	16	0	1	1
Q60–Q64	Urinary system	104	4	162	5	7	4
Q65–Q79	Musculoskeletal system	174	6	287	8	11	7
G80–G85	Skin, breast integument phakomatoses	7	0	11	0	1	1
Q86–Q89	Other	86	3	100	3	4	3
Q90–Q99	Chromosomal abnormalities total	1,012	38	1,088	32	32	20
Q90	Down’s syndrome	544	20	570	17	3	2
0910–Q913	Edwards’ syndrome	211	8	226	7	8	5
Q914–Q917	Patau’s syndrome	79	3	93	3	7	4
Q92–Q99	Other	178	7	199	6	14	9
	Other conditions total	483	18	663	19	22	14
P00–P04	Fetus affected by maternal factors	165	6	235	7	1	1
P05–P08	Fetal disorders related to gestation and growth	27	1	38	1	11	7
P35–P39	Fetus affected by congenital infectious disease	0	0	0	0	0	0
P529	Intercranial nontraumatic hemorrhage of fetus	7	0	7	0	4	3
P832–P833	Hydrop fetalis not due to hemolytic disease	39	1	81	2	1	1
O30	Multiple gestation	39	1	45	1	0	0
O41	Disorder of the amniotic fluids	4	0	8	0	0	0
Z20–Z22	Exposure to communicable disease	6	0	7	0	5	3
Z80–Z84	Family history of heritable disorder	154	6	191	6	0	0
E84	Cystic fibrosis	15	1	17	0	0	0
G71	Disorder of the muscles	11	0	18	1	0	0
	Other	11	0	11	0	0	0
	Not known^d	5	0	5	0	0	0

^a ’Other’ conditions may be available by ICD-10 code on request.

^b Percentages are rounded and may not add up to 100.

^c ICD-10 codes are taken from the International Statistical Classification of Diseases and Related Health Problems (10th revision), published by the World Health Organization.

^d ‘Not known’ includes one case that on further investigation was found to be performed under Ground C and not Ground E, and it was too late to amend the tables.

² The all mentions totals show abortions where more than one medical condition is reported. Totals therefore do not equal the number of abortions performed under Ground E.

In 2012 in England and Wales, congenital malformations were reported as the principal medical condition in nearly half (44%) of the 2,692 abortions undertaken under Ground E. The most commonly reported malformations were of the nervous system (23%), cardiovascular system (7%) and musculoskeletal system abnormalities (6%). About one-third (38%) of pregnancies terminated under Ground E were reported to be for chromosomal abnormalities. Down’s syndrome was the most commonly reported and accounted for 20% of all Ground E cases[23] (Table 18.2).

Major structural abnormalities still constitute a major cause of perinatal mortality, accounting for 9.6% of stillbirths and 21.5% of neonatal deaths in 2009 in the UK[29].

In 2012 in Scotland, 159 (1.3%) abortions were carried out under Ground E of the Abortion Act. Of these, 30 were for Down’s syndrome, 26 for other chromosomal anomalies, 15 for anencephaly and 13 for musculoskeletal conditions[23] (Table 18.3).

Table 18.3 Legal abortions: countries of the UK by principal medical condition for abortions performed under Ground E in 2012 [23]

Country of abortion	Numbers and percentages
Country of abortion	England and Wales		Scotland		UK
All legal abortions	190,972	100%	12,447	100%	203,419	100%
Total under Ground E	2,692	100%	159	100%	2,851	100%
Nervous system (Q00–Q007)	607	23	41	26	648	23
Other congenital malformations (Q10–Q89)	590	22	40	25	630	22
Chromosomal abnormalities	1,012	38	56	35	1,068	37
Other	483	18	22	14	505	18

Between 2006 and 2009 the number of abortions performed per year under Ground E in England and Wales was static. Between 2009 and 2012 there was an increase of 29%, whilst overall there was a slight fall in the total number of abortions. The percentage of the total number performed under Ground E has increased from 0.98% to 1.45% over 5 years from 2007. These figures may be a reflection of improved antenatal screening programmes (Table 18.4).

Table 18.4 Legal abortions performed under ground E, by gestation weeks, England and Wales in 2006–2012 [23]

Year	Total number abortions	Total abortions under Ground E (% of total number abortions)	Abortions under Ground E under13 weeks (% of abortions under Ground E)	Abortions under Ground E 13–19 weeks (% of abortions under Ground E)	Abortions under Ground E 20–23 weeks (% of abortions under Ground E)	Abortions under Ground E ≥24 weeks (% of abortions under Ground E)
2006	193,700	2,036 (1.05)	315 (15.5)	1,018 (50.0)	567 (27.8)	136 (6.7)
2007	198,500	1,939 (0.98)	291 (15.0)	1,000 (51.6)	513 (26.5)	135 (7.0)
2008	195,296	1,988 (1.02)	309 (15.5)	999 (50.3)	556 (28.0)	124 (6.2)
2009	189,100	2,085 (1.10)	329 (15.8)	1,020 (48.9)	600 (28.8)	136 (6.5)
2010	189,574	2,290 (1.21)	382 (16.7)	1,116 (48.7)	645 (28.2)	147 (6.4)
2011	189,931	2,307 (1.21)	338 (14.7)	1,191 (51.6)	631 (27.4)	147 (6.4)
2012	185,122	2,692 (1.45)	386 (14.3)	1,431 (53.2)	715 (26.6)	160 (5.9)

Abortions over 24 weeks of gestation accounted for less than 0.1% of the total. Although there were 160 abortions at or over 24 weeks in 2012 in England and Wales compared with 135 in 2007, they represent 5.9% of the total number of abortions carried out under Ground E compared with 7% in 2007. Whilst the proportion of abortions at 24 weeks and over has fallen slightly since 2007 there has been no change in the proportion at 20–23 weeks of gestation, which has remained at around 27% of the total under Ground E (Table 18.4).

Current national guidelines recommend that routine screening for Down’s syndrome should be performed before 14 completed weeks of pregnancy to allow early decisions to be made, including whether to have an invasive diagnostic test and, if fetal aneuploidy is confirmed, whether to undergo induced abortion[30]. This would allow women to have an abortion at an earlier gestation with a reduced complication rate and avoid the necessity of feticide.

There were no abortions associated with rubella under Ground E in 2012. In the past 10 years, there have been seven abortions associated with rubella in England and Wales: two in 2003, three in 2005, and one in each 2006 and 2007[23].

In 2012, 75% of abortions under Ground E overall were performed medically compared with 48% of all abortions. Under 15 weeks of gestation, approximately half of the abortions under Ground E were medical. At 15–16 weeks, the ratio of medical to surgical abortions under Ground E was 4:1 and at 17–19 weeks it was 9:1. At 20–21 weeks, 99% were performed medically and at 22 weeks and over it was 97%[23] (Table 18.5).

Table 18.5 Legal abortions performed under ground E by gestation weeks, residents of England and Wales numbers in 2012[23]

England and Wales, residents	Number of cases
England and Wales, residents		Gestation weeks for abortions performed under Ground E
Procedure	Total	Under 13	13 & 14	15 & 16	17 to 19	20 & 21	22 and over
Total abortions	2,692	386	795	353	283	482	393
Surgical	676	213	344	72	28	6	13
Vacuum aspiration	452	175	261	16	0	0	0
Dilatation and evacuation	154	16	64	52	19	3	0
Feticide with a surgical evacuation^a	70	22	19	4	9	3	13
Medical	2,016	173	451	281	255	476	380
Antiprogesterone with or without prostaglandin	1,463	165	420	256	221	372	29
Other medical agent	127	8	31	25	29	24	10
Feticide with a medical evacuation^b	426	0	0	0	5	80	341

^a Includes feticide with no method of evacuation and surgical ‘other’.

^b Includes eight cases where use of feticide was not confirmed at time of publication.

The National Down’s Syndrome Cytogenetic Register (NDSCR) began collecting data for England and Wales in 1989[31]. Screening tests for Down’s syndrome were introduced at that time, and since 2003 when the UK National Screening Programme was introduced, first-trimester screening has become gradually available to all women in England and Wales. This has resulted in an increase in the number of antenatal diagnoses of Down’s syndrome. An increase in maternal age has contributed to this rise. The prevalence of Down’s syndrome has also increased as pregnancies that would previously have resulted in miscarriage are being diagnosed.

In 1989, the NDSCR reported a total of 1066 Down’s syndrome diagnoses, 318 (30%) of which were made antenatally. In 2012, the total number of diagnoses had risen to 1982, of which 1259 (64%) were antenatal. Around 90% of women with an antenatal diagnosis of Down’s syndrome undergo termination of pregnancy. There has been a slight decrease in this proportion, from 92% between 1989–2010 to 90% in 2011–2012. However, the NDSCR data show that overall the number of terminations of pregnancy that were performed after a diagnosis of Down’s syndrome has increased more than fourfold from 302 in 1989 to 1331 in 2012.

First-trimester screening has resulted in the diagnosis of Down’s syndrome being made earlier in pregnancy, thereby allowing termination of pregnancy to be carried out at lower gestations. In women under 35 years of age in 1989, only 2% of abortions after a diagnosis of Down’s syndrome were performed under 15 weeks of gestation, which increased to 46% in 2012. In women over 35 years old, the increase was from 18%–50%. The proportion of terminations of pregnancy performed at 21 weeks of gestation and over reduced from 52% in 1989 to 12% in 2012 in women under 35, and from 19% to 6% in women over 35 years old[26].

These figures reflect those of the UK Department of Health statistics but are considerably higher, possibly as in some cases the abortion if under 24 weeks of gestation, will have been legally performed under clause C of the Abortion Act or due to under-reporting to the Department of Health.

The number and prevalence of live births affected by Down’s syndrome have not changed significantly, there being 750 cases in 1989 and 775 in 2012.

Complications

Complications of abortion increase with gestational age. This is especially the case with medical abortion. Complications were reported in 278 cases in 2012, a rate of about one in every 700 abortions, which was the same as in 2011 and 41% less than in 2002[22] (Table 18.6).

Table 18.6 Legal abortions: complication^a rates by procedure and gestation weeks, residents of England and Wales in 2012[23]

England and Wales, residents	Complication rates per 1,000 abortions
Gestation weeks	Total all procedures	Procedure
Gestation weeks	Total all procedures	Surgical	Medical
Total complications (number of cases)	278	91	187
All gestations	2	1	2
3–9 weeks	1	1	1
10–12 weeks	2	2	3
13–19 weeks	5	1	16
20 weeks and over	12	3	29

^a Complications include hemorrhage, uterine perforation and/or sepsis, and are those reported up to the time of discharge from the place of termination.

There were no maternal deaths following abortion notified to the Department of Health in 2012. In the triennium 2006–2008, there were 107 direct maternal deaths in the UK. Two were associated with abortion and both of these were from genital tract sepsis. There were a total of 628,342 abortions in the triennium 2006–2008, making the mortality rate of induced abortion 0.32/100,000[32].

References

1.Abortion Act 1967. London: HMSO; 1967. http://www.legislation.gov.uk/ukpga/1967/87/contents.

2.Human Fertilisation and Embryology Act 1990. London: HMSO; 1990. http://www.legislation.gov.uk/ukpga/1990/37/contents.

3.Statham H, Solomou W, Green J. Late termination of pregnancy: law, policy and decision making in four English fetal medicine units. BJOG 2006; 113: 1402–11.

4.Abortion Act 1967. London: HMSO; 1967. https://www.gov.uk/government/publications/abortion-notification-forms-for-england-and-wales.

5.Abortion Act 1967. Section 3. London: HMSO; 1967. http://www.legislation.gov.uk/ukpga/1967/87/section/3.

6.Draper E, Alfirevic Z, Stacey F, et al. for the EPICure Study Group. An investigation into the reporting and management of late terminations of pregnancy (between 22+0 and 26+6 weeks of gestation) within NHS Hospitals in England in 2006: the EPICure preterm cohort study. BJOG 2012; 119: 710–5.

7.R v Smith [1974]. 1 All ER 376, 1 WLR 1510, 58 Cr App Rep 106.

8.Care Quality Commission (CQC). Findings of termination of pregnancy inspections 2012. http://www.cqc.org.uk/media/findings-termination-pregnancy-inspections-published.

9.Department of Health. Guidance in relation to requirements of the Abortion Act 1967, May 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/313459/20140509_-_Abortion_Guidance_Document.pdf.

10.Janaway v Salford Health Authority: All England Law Rep 1988 Dec1; [1988] 3: 1079–84.

11.Doogan and Wood v. NHS Greater Glasgow and Clyde Health Board [2013] CSIH 36 P876/11. http://www.bailii.org/scot/cases/ScotCS/2013/2013CSIH36.html.

12.General Medical Council. Personal beliefs and medical practice, 2013. http://www.gmc-uk.org/Personal_beliefs_and_medical_practice.pdf_51462245.pdf.

13.Royal College of Nursing. Termination of pregnancy, an RCN nursing framework, 2013. http://www.rcn.org.uk/__data/assets/pdf_file/0004/529654/Terminationofpregnancy_WEB.pdf.

14.Kelly v Kelly [1997]. ScotCS CSIH_2 (24 May 1997). http://www.bailii.org/scot/cases/ScotCS/1997/1997_SC_285.html.

15.Hone v Hansell [unrep, March 2001].

16.Paton v BPAS [1979] QB 276.

17.Paton v UK [1981] 3 EHRR 408.

18.Northern Ireland Department of Health, Social Services and Public Safety. The limited circumstances for a lawful termination of pregnancy in Northern Ireland. A guidance document, 2013. http://www.dhsspsni.gov.uk/guidance-limited-circumstances-termination-pregnancy-april-2013.pdf.

19.Northern Ireland Department of Health, Social Services and Public Safety. Written statement to the Assembly, 2012. http://www.dhsspsni.gov.uk/termination-statement.

20.Northern Ireland Statistics and Research Agency. Birth and Deaths Reports. www.nisra.gov.uk/demography/default.asp23.htm.

21.Lynn F, McNeill J, Alderdice F. Current trends in antenatal screening services: results from a regional survey. Ulster Med J 2010; 79(1): 12–5.

22.Royal College of Obstetricians and Gynaecologists (RCOG). Termination of Pregnancy for Fetal Abnormality in England, Wales and Scotland. Working Party Report. London: RCOG, 1996.

23.Department of Health. Report on abortion statistics in England and Wales for 2012, July 2013. https://www.gov.uk/government/publications/report-on-abortion-statistics-in-england-and-wales-for-2012.

24.Nuffield Council on Bioethics. Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues. London: Nuffield Council on Bioethics, 2006. www.nuffieldbioethics.org/go/ourwork/neonatal/publication_406.html.

25.British Association of Perinatal Medicine. Palliative care (supportive and end of life care). A framework for clinical practice in perinatal medicine, 2010. http://www.bapm.org/publications/documents/guidelines/Palliative_Care_Report_final_%20Aug10.pdf.

26.Royal College of Paediatrics and Child Health (RCPCH). Withholding or Withdrawing Life Sustaining Treatment in Children: A Framework for Practice, 2nd edn. London: RCPCH, 2004. [www.library.nhs.uk/GUIDELINESFINDER/ViewResource.aspx?resID=298393].

27.Royal College of Obstetricians and Gynaecologists (RCOG). Additional report from the RCOG Ethics Committee. Further issues relating to late abortion, fetal viability and registration of births and deaths. London. RCOG, 2001.

28.National Health Service Scotland. Information Services Division (ISD) Scotland Abortion Statistics 2012, May 2013. http://www.isdscotland.org/Health-Topics/Sexual-Health/Publications/2013-05-28/2013-05-28-Abortions-Summary.pdf?58079165221.

29.Healthcare Quality Improvement Partnership UK. Confidential Enquiry into Maternal and Child Health: Perinatal Mortality, 2009. www.hqip.org.uk/assets/NCAPOP-Library/CMACE-Reports/35.-March-2011-Perinatal-Mortality-2009.pdf.

30.National Institute for Clinical Excellence (NICE). Antenatal Care: Routine Care for the Healthy Pregnant Woman. NICE Clinical Guideline CG62. London: NICE, 2008 http://guidance.nice.org.uk/CG62.

31.Public Health England. The National Down Syndrome Cytogenetic Register for England and Wales. 2012 Annual Report, 2013. http://www.wolfson.qmul.ac.uk/current-projects/downs-syndrome-register#annual-report

32.Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives. Reviewing maternal deaths to make motherhood safer: 2006–2008. BJOG 2011; 118 (Suppl. 1): 1–203.