Is the rate of abortion complications falling?

15 December 2020

Kevin Duffy, independent health consultant, comments on how the rate of complications resulting from abortion in the UK may be going under-reported.

Official government data shows that each year, over 300 women suffer complications from abortion.

Statistics from the Department of Health and Social Care for the last five years, shows that each year, 313 women who have an abortion in England and Wales, suffer from complications requiring hospital treatment, including haemorrhage, sepsis, and uterine perforations. This year, the reported number could be as low as 200, not because abortion has all of a sudden become safer but because abortion providers are under-reporting complications.

In a recent letter to The Telegraph, Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, expressed concern about Baroness Stroud’s suggestion that early medical abortions at home are a terrible idea.” He said: “More than 40,000 women have now had an early medical abortion at home and early data shows that complications have decreased since its introduction.”

He can be forgiven for making this mistake, especially if he has been referring to official data published by the Department of Health and Social Care (DHSC). In its response to a freedom of information request, FOI-1257670, the DHSC states that in the months April to June 2020, there were 23,061 telemedicine-enabled abortions at home in which women self-administered both mifepristone and misoprostol. It reports just one complication, a case of haemorrhage. This represents a case rate for complications of 0.043 per 1,000 abortions.

This is notable because in the same data table the DHSC shows 63,876 abortions, up to ten weeks gestation, in the first six months of 2020 in which one or both abortion pills were taken in-clinic. It reports 29 complications: 26 haemorrhage, 2 sepsis, and 1 uterine perforations. This case rate is 0.5 complications per 1,000 abortions, lower than the average case rate for abortions under ten weeks gestation, over the five-year period to 2019, which is 0.74 per 1,000.

So, if the complications rate has been at least 0.74 per 1,000 abortions for many years, why would it now drop by a factor of 17 times, to just 0.043 per 1,000? Could this really be because abortion at home is so much safer than when the same medications are administered in a clinic setting?

Of course not, and even suggesting that is ridiculous.

So, what is happening?

These abortion complications data are gathered by the DHSC from the HSA4 forms completed and submitted by the abortion providers. This form must be completed by the doctor who certifies the abortion and prescribes the abortion pills for use at home; it must be sent to the Chief Medical Officer within fourteen days of the abortion. The DHSC states that the data it reports for “total complications include haemorrhage, uterine perforation and/or sepsis and are those reported up to the time of discharge from the place of termination. Therefore, complications that occur after discharge may not be recorded.”           

Under the temporary abortion at home approval, we find that doctors are completing and submitting the HSA4 form at the same time as the abortion pills are being posted to the woman. At that time, there are no complications because the pills have not yet been administered and since there is insufficient follow-up with women at home, it is highly likely that abortion providers are now under-reporting complications which will still be occurring, at least at the same rate as before; 0.74 complications per 1,000 abortions.

By ‘complication’ we mean those serious adverse events which normally require treatment in a hospital setting: haemorrhage, sepsis, and uterine perforations. These are distinct from the otherwise to be expected side-effects which include incomplete abortions with retained products of conception requiring surgical intervention.

In June 2020, there were 8,097 women who used the telemedicine pills-by-post abortion service. We listened to a number of these telephone calls and it is clear that both BPAS and Marie Stopes UK are directing their clients to self-assess for any signs of complications and if necessary, to report to their local hospital. Could it be that the complications which previously occurred in the abortion clinic and were thus reported on the HSA4 forms, are now occurring at home and being self-managed by women who make their own way to local A&E and Emergency Departments?

We have included extracts from some of these call transcripts at the end of this post.

We are grateful to Christian Hacking, Political Liaison Officer at CBR UK, for sharing data and his analysis of freedom of information requests about abortion complications being managed at various hospitals across England. Over the next few months, we will continue to evaluate these responses and report our findings. One of the responses received is from the Lewisham and Greenwich Hospital which reports managing seven admissions from 31 March 2020 to 1 September 2020 with complications after medical termination of pregnancy.

That’s seven complication cases managed at just one local hospital, seven cases which are not included on HSA4 forms and thus will not be included in the DHSC’s official abortion statistics reporting.

Temporary approval for abortion-at-home was granted by the Secretary of State for Health and Social Care, Matt Hancock, on 30 March 2020, and since then to the end of 2020, it is likely that 69,000 women have self-administered both pills at home after just a telemedicine consultation (extrapolated from DHSC data for April-June 2020). Since it is unlikely that complication rates will be much lower than in previous years, this would indicate that as many as fifty women will have needed to attend their local hospital for emergency treatment.

At the time of their complications, these 50 women were not being cared for by the abortion provider who prescribed and supplied the abortion pills, and who took payment from the NHS. Rather, they were left on their own, to make their own assessment of their need to seek emergency hospital care.

50 in nine months is not as BPAS has stated in the past, ‘a vanishingly small number’. These, often young and vulnerable, women need better care than this.

There are open consultations being held by the government in Scotland, England, and Wales in which you are being asked if this temporary approval for telemedicine DIY abortion should now be made permanent.

Please take this opportunity to say “No” and to tell the government that it needs to cancel its temporary approval, reverting back to the prior arrangements in which women seeking an abortion need to first attend a clinic. It is essential for women’s safety that they are clinically assessed for their eligibility and suitability for an early medical abortion at home, and that the abortion provider is required to follow up each woman who chooses to self-administer at home until the procedure is complete.

Some organisations have posted guidance on how you can make your own personal response to these consultations (you can respond to all three); best to start with the consultation in Scotland since it will be the first to close, on 5 January 2021.

Here are relevant links:

As noted above, here are extracts from the call transcripts which reveal what BPAS and Marie Stopes are telling their clients:

BPAS Abortion Provider speaking with Anna

“Then when you do start to bleed, it will be quite heavy and painful for at least a few hours. We do want you bleeding fairly heavily because we obviously want you to be passing the pregnancy, but we don’t want you to be bleeding too heavily. So, if you’re ever completely soaking two or more really thick sanitary towels in an hour, and you do that for two hours consecutively, that’s when you need to be going to hospital.”

“If you ever feel out of control with the pain or the bleeding or anything like that, you need to get yourself to hospital because they’ll be able to help you there, okay?”

“Infection is about 2-in-1000. We don’t give out antibiotics anymore because of antibiotic resistance. It’s just up to you to watch out for signs. So that’s if you get any smelly discharge and just feeling really under the weather or you’ve got abdominal pain that goes on for a few days afterwards, that kind of thing, then please do get in contact with your doctor to see if they think you need any antibiotics.”

BPAS Abortion Provider speaking with Lisa

“So, I’m not sending you for a scan. An ectopic pregnancy is the pregnancy that grows outside the womb. It’s very rare. If you know the signs and symptoms, and you get any of these, go to hospital. So, if you get them symptoms, the symptoms of ectopic, you go to accident and emergency immediately. Like I say, it’s very rare, one in 7,000 women.”

“I’ve told you; you’re going to bleed heavy, but you shouldn’t be flooding through sanitary pads. So, if you have to change four flooded pads in two hours, that’s our red flag for haemorrhage and then you need to go to hospital. At the hospital, they obviously take over your care, but it could be that you end up with a surgical procedure to remove what’s causing the bleeding. You might need a blood transfusion.”

Marie Stopes UK Abortion Provider speaking with Laura

“You can continue to bleed up to two weeks sometimes, but just keep an eye on your bleeding. If you’re concerned about anything clinically, then call 111 or go to A&E.”

“We would class too much blood loss is if you were soaking through more than two thick maternity pads within one hour. If that happened, or if you had any symptoms of infection, it’s really important that you go to hospital, okay?”

Marie Stopes UK Abortion Provider speaking with Nikki

“In terms of infection, once you stop bleeding, look for the signs of infection if you’re feeling generally unwell. If you’ve got an increased temperature, if you’ve got abdominal pain that won’t go away or if you’re producing an excessive amount of discharge with an abnormal colour or odour. Please go to your GP and they’ll start you on some antibiotics.”

BPAS Abortion Provider speaking with Claire

“It is low risk to get an infection, and in your booklet, there will be lots of information about signs and symptoms of infection so that you can basically keep your eye out for any of those. If you feel concerned, if you think they are developing, you need to see your own GP.”

“Bleeding can be heavy initially, but you do need to monitor it, like I said. If you’re concerned that your blood loss is starting to become too heavy, and in your booklet and on our website is information about normal blood loss and what is starting to become too heavy. You follow that advice, and if you’re concerned that it’s heavy you should pop along to your local hospital to get assessed, just to make sure that you’re not bleeding too heavy. At the hospital they may have to do some extra little procedures to check what’s going on if you are bleeding heavy. One of those involves a minor procedure called a laparoscopy. It basically involves them having to put a little camera into your abdomen, keyhole surgery, so literally little hole in your tummy to have a look around. It’s extremely rare for that to be necessary, but it can happen. They may also have to consider a blood transfusion, which obviously means they need to give you some blood because otherwise you’re going to be poorly because you bled heavy, okay?”

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