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Comments on the Draft Guidelines by the
RCOG for the Practice of Abortion
Dr. Philip Ney
26/09/11
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.
Philip G. Ney MD DPM FRCP(C)
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