Abortion complications massively under-reported

19 October 2023

Independent public health consultant Kevin Duffy writes on the extensive under-reporting of complications following medical abortions.

Abortion providers are massively under-reporting the incidence of complications arising from an incomplete medical abortion. They also under-state the risk of an incomplete abortion when consenting women for this procedure.

Thankfully, Lord Jackson has questioned the Government about this critical issue and is holding the Department for Health and Social Care (DHSC) to account to ensure its data reporting is complete and accurate.

Women should be told the truth: there is a 1-in-17 risk that early medical abortion may be incomplete, requiring further medical intervention.

Parliamentary questions

On 19 June 2023, Lord Jackson of Peterborough tabled a question asking the Government what steps it was taking to monitor those cases in which a woman presents with complications after accessing medical abortion via telemedicine.

In response, Lord Markham (Parliamentary Under-Secretary Department of Health and Social Care) said on 25 July 2023 that the DHSC was aware that complications arising after discharge were not being reported by the abortion providers.

”For at-home abortion, discharge is effectively when the abortion pills are posted to the woman, at which time there would be no complications because the pills have not yet been taken by the woman.”

Lord Markham wrapped up his response by noting that the DHSC is “taking forward a project to improve our understanding of the data available on abortion complications.”

In a related question, tabled on 6 July 2023, Lord Jackson asked the Government if it plans to update the DHSC required standard operating procedures (RSOPs) to require the independent sector abortion providers to gather and report data on all complications arising from at-home abortions, across all clinical settings. In his response on 24 August 2023, Lord Markham stated that there are no plans to update the RSOPs to include expectations related to the reporting of complications. He again acknowledged that for medical abortions at-home “complications are less likely to be known by the provider and recorded on the HSA4.”

”The HSA4 is the official form that an abortion provider must use to notify the DHSC about every abortion performed.”

Lord Markham went on to say that these complications are recorded when a woman presents for treatment at an NHS hospital.

”So, the DHSC knows that abortion providers are not reporting all complications and it knows that some of these missing data are available from within the NHS.”

Lord Markham wrapped up his response by stating, “To improve the quality of data available on abortion complications, the Department is taking forward a project to improve our understanding of the data.”

On 6 September 2023, Lord Jackson followed up on the 24 August response from Lord Markham, asking why the DHSC is not planning to update the RSOPs to mandate the collation and reporting of all complications arising from at-home medical abortions.

On 14 September 2023, Lord Markham stated that the RSOPs require notification of any complication known at the time of submitting the HSA4. He goes on to say that data records of cases in which a woman presents with abortion complications at other health facilities “are beyond the scope of the RSOPs.” In this response he does not mention the department’s data review project.

DHSC is aware of under-reporting

So, what do we learn from these formal parliamentary interactions?

  • The Department of Health and Social Care is fully aware that independent sector abortion providers are not reporting on all complications arising from at-home medical abortions.
  • The Department knows that some women present for treatment for complications arising at NHS hospitals and these cases are recorded in systems such as Hospital Episodes Statistics.
  • The DHSC acknowledges the need to improve the quality of data available on abortion complications and has established a project to improve its understanding of these data.
  • The DHSC could easily use data from these different sources, HSA4 forms and hospital record systems, to report more fully on the numbers and rate of complications arising from at-home abortions, but so far it has not done so.

Official complication rates are far too low

Official abortion statistics for England and Wales in 2022, show a complication rate for early medical abortion, <10w, of 0.03% (cell D9 of T8). This rate will have been derived from the HSA4 forms, collated by the DHSC. In the first six months of 2022, there were 92,159 at-home medical abortions (only misoprostol or both medications), so the number of reported complications was 28.

The Royal College of Obstetricians and Gynaecologists (RCOG) provides information for those who are considering an abortion. Under the section, ‘What is the risk of the abortion failing?’, it states: “All methods of early abortion carry a small risk of failure to end the pregnancy and therefore a need to have another procedure. This is uncommon, occurring in fewer than 1 in 100 women.”

In a following section, ‘Are there risks after the abortion?’, RCOG states: “The uterus may not be completely emptied of its contents and further treatment may be needed. This happens in fewer than 6 in 100 women having a medical abortion. An operation may be needed to remove the pregnancy tissue within the uterus.”

So RCOG, the leading expert organisation on women’s reproductive care, knows that medical abortion treatment can fail or be incomplete, sometimes the woman remains pregnant, sometimes she has retained products of conception, and when this happens, she will need another procedure, an operation to complete the abortion. The rate for these complications is stated by RCOG to be about 6%, about 1-in-17.

On its website, the NHS states: “the main risks of medical abortion are needing another procedure to remove parts of the pregnancy that have stayed in the womb: this happens to about 70 out of 1,000 women.” (7%)

There is a very significant difference between the complications rate reported in the official statistics, 0.08% (medical abortions all gestations, cell D8 of T8in DHSC spreadsheet linked above), and these rates stated by the RCOG and NHS of about 6%. Applying this rate to the 92,159 at-home abortions in the first six months of 2022, there may have been as many as 5,500 women needing further medical treatment at their local NHS hospital, a far cry from the 28 indicated in the official government statistics.

Women should know the truth

I agree with Lord Marham; there is an urgent need to better understand the data available on medical abortion complications and to improve the completeness and accuracy of the official reporting of these. I hope that Lord Jackson will continue his questioning of this critical issue to hold the DHSC to account.

At the time of writing, mid-October 2023, both BPAS and MSI Reproductive Choices are understating the risk of these complications. BPAS states a 2% risk of an incomplete abortion, with retained products of conception. MSI-RC states a 3% risk of an incomplete abortion.

BPAS and MSI-RC, the largest independent sector abortion providers, pride themselves on the quality of care that they offer women and the importance of giving clear and accurate information to help her choose. Women cannot give their informed consent unless they are given all relevant information and so we call on both organisations to update their guidance to align with the RCOG and NHS; tell women that there is a 1-in-17 risk that the abortion pills will not work and that they will need further medical intervention to complete the abortion, either at a provider clinic or at their nearest NHS emergency department.

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