Acute Health Division
Department of Human Services
AVictorian Government Department, Australia
Medical Practitioners Board of Victoria
Report on late term terminations of pregnancy
April 1998
Submissions
The Board is grateful for the assistance of the following organisations that contributed to its understanding of the issues by writing very thoughtful and comprehensive submissions.
All the submissions that were received were read and utilised in writing the report. The following is an indication of some of the key or unique points that were expressed by the authors of the submissions and does not reflect the complexity or depth of each submission.
Invited Submissions from academic and major health care institutions
The Board invited submissions from the following professional and academic organisations and major health care institutions.
1. Australian College of Midwives Incorporated, Victorian Branch
The major concern expressed in this submission was the protection of women’s rights in screening programmes, and the moral issues of termination for reasons of fetal abnormality. It was considered that women may not be given sufficient information to make a decision about screening and may suffer distress when a false positive result to screening is given. The submission expressed concern about delayed screening tests that are "putting the timing of mid-trimester abortions at later and later intervals in women’s pregnancy".
2. Australian College of Paediatrics
Written and oral submissions
Ethics
The College does not hold views on the ethics of late terminations of pregnancy, but considers that during pregnancy, the rights and wishes of the mother should take priority in any decisions about her pregnancy. From the moment of birth, the infant has the status of a normal individual, and from then on, the rights of the infant should have priority. The role of the paediatrician is to provide good quality advice to the mother on the outcomes of the pregnancy and to assist her in her decisions.
Viability
Survival of an infant born at 24 weeks gestation is now routine with 70 - 80% survival in level 3 neonatal institutions, provided the delivery has occurred at that institution. Survival rates at 23 weeks gestation are increasing with 50 - 70% surviving if offered treatment. Survival at 22 weeks is very uncommon although there have been some reported cases. At this stage, the fetal lungs are barely cannulated, and progressive pulmonary disease will usually follow. The range of biological maturity explains some of the early survivals, but it is considered that survival under 22 weeks gestation is not possible.
If an infant were born alive at a level 3 institution at 24 weeks gestation, it would be offered intensive care with a 70% survival rate, provided that there are no significant abnormalities. In the last 10 to 15 years, there has been the development of competence in regional centres to stabilise such infants before transfer to a level 3 institution.
At 23 weeks gestation, there are considerable risks of poor outcome with survival. Some neonatologists would only provide intensive treatment if the parents have made an informed decision about this. Some neonatologists would offer a "Trial of Life" basis of care, with review every 8 hours and if there has been clear deterioration, would consider providing conservative rather than intensive care. At 22 weeks, intensive treatment would only be provided if there were special circumstances as the outcome is hazardous for the infant with a significant risk of death or disability, and treatment is ethically questionable.
The Victorian Collaborative Study Group studies showed that infants born under 1000 grams weight in 1991-2 had the following outcome:
Severe disability 6%
Moderate disability 7%
Mild disability 19%
Those with lower gestation had higher rates of mortality and disability.
These observations are likely to influence the response of a neonatologist confronted with the situation of an elective termination that resulted in an infant born alive. In those infants born with severe fetal abnormality, the burden of treatment and the outcome is so poor that it is unlikely that aggressive resuscitation and care could be justified.
It has been argued that intensive treatment of infants under 26 weeks gestation is "experimental" and should be carried out only at the parents’ absolute discretion.
The College emphasises that the child is a moral and personal entity and should be managed in its own right, and that good communication between all professionals and the parents is essential before a decision to terminate on grounds of fetal abnormality is made.
3. Australian Medical Association, Victorian Branch
The Victorian AMA is not currently in a position to provide advice specifically relating to the ethical and clinical issues associated with late term termination of pregnancy.
2. Australian and New Zealand College of Anaesthetists
The College submits that from an ethical point, each anaesthetist has the choice of declining to anaesthetise for terminations of pregnancy. However, it is safer for the patient if she receives a properly conducted anaesthetic in a recognised institution.
There are greater risks where terminations are performed later. These include greater risk of blood loss (from 14-15 weeks) and aspiration. The anaesthetic is more complex, the risk of complications is greater and the duration of the operation and recovery is greater.
5. Family Planning Victoria Inc
Family Planning Victoria does not perform terminations but does provide counselling and referral. It submitted that although early termination of pregnancy is preferable to late terminations, it is their view that late terminations of pregnancy will always be necessary for a small percentage of women who have special circumstances. In the experience of Family Planning Victoria, the group seeking terminations beyond 16 weeks were often adolescents or disadvantaged women who lack support.
FPV supported the International Planned Parenthood Federation Statement and in doing so recognised a woman’s right to choice and to receive high quality services including referral to high quality termination services. It supported the provision of accurate information relating to abortion and is an advocate for provision of safe legal and accessible abortion through consultation and liaison with government and other community organisations. The Statement defends safe, responsible and legal abortion from unjustified criticism and/or restriction.
6. Mercy Hospital for Women, Clinical Director - Obstetrics and Gynaecology
This submission protested "against the establishment of a ‘for profit’ clinic to perform so called ‘late terminations of pregnancy". It is stated that where there are severe fetal abnormalities, care of the woman demands an appropriate environment with access to specialised diagnostic and support services. It is stated that there is moral argument that such babies are entitled to their intra-uterine life, and should succumb to their abnormality rather that to iatrogenic prematurity or the means of delivery.
It was further stated that if delivery was required for maternal reasons before 26 weeks, Caesarian section should be performed as early as 24 weeks gestation and the baby given intensive care, as survival rates may be better than 50% between 24 and 26 weeks gestation.
7. Monash Medical Centre
Oral submissions
Monash Medical Centre is a referral centre for approximately half the state of Victorian and would perform approximately 50 terminations for fetal abnormality a year. There are several units responsible for aspects of care of women seeking termination.
The Contraceptive and Counselling Unit
The Fetal Diagnostic Unit
The Feto-Maternal Medical Unit
Other general Obstetric Units
Terminations for psychosocial reasons are not performed at Monash Medical Centre after 18 weeks gestation. There may be exceptional circumstances that could extend this till 20 weeks, but in no circumstances beyond the stage of viability. An example could be that of a 16 year old retarded girl who had been raped by her supervisor in a sheltered workshop and was terminated at 19 weeks.
The centre receives a request for termination after 20 weeks gestation for psychosocial reasons infrequently (about 1 every 3-4 weeks), and when it does so, the woman is informed that it is too late and is offered further care of the pregnancy.
Terminations after 20 weeks would be by induction of labour by prostaglandins. Although private obstetricians and gynaecologists outside the Centre could perform this method, there is no evidence to support that it is being done.
There is no training programmed for the procedure of Dilatation and Evacuation. The Unit Head is doing all these.
Counselling is offered to all women undergoing termination in the second trimester for psychosocial reasons (14-19 weeks gestation), but the offer is seldom accepted. Counselling is provided for all women who have termination for fetal abnormality, and is given by members of the team who are responsible to the care of the parents. This includes geneticists, gynaecologists, nurse coordinator and counsellor.
Fetal Diagnostic Unit
Monash Medical Centre
Written and oral submission
Questions relevant to late termination for fetal abnormalities
The method of diagnosing the abnormality
Most diagnostic procedures for fetal abnormality are carried out between 12 and 20 weeks gestation. Although modern techniques of ultrasonography allow diagnosis to be made earlier than previously, and technology allows most conditions to be identified at 15 weeks gestation, some abnormalities cannot be diagnosed until 18 weeks. There are other instances when fetal abnormality could have been diagnosed earlier but there was a late referral or a delay in considering termination.
Because of the rapid expansion of techniques and expertise in ultrasonography, and because the numbers of fetal abnormalities are small, it is not possible for specialists working in isolated communities in the country to maintain expertise, and special arrangements for rapid referral from rural areas are needed.
The process of arranging termination
The process requires consultation, arrangement for performing tests, counselling for the parents and organising the termination if this is requested. This may well take the pregnancy beyond 20 weeks gestation.
The severity of the fetal abnormality
At every stage of the process of investigation and in consideration of termination, parents are consulted. Where the father is in a de facto relationship, the hospital tries to involve him. However, the mother has the major say in decisions.
The question of where to draw the line in embarking on termination, when requested, depends on the severity of the abnormality and a consensus with the treating doctor, the hospital staff, the institution and the general community.
There is no governing legislation or policy regarding the upper limit of gestation when terminations for fetal abnormality may be done. At Monash Medical Centre, there is no upper limit for terminations for lethal abnormality, but for lesser abnormalities, where the infant may be expected to survive, the upper limit relates to viability. This is regarded as 22 weeks gestation but may be extended to 24 weeks.
Arrangements at Monash Medical Centre
There is a separate ward with nurses who are prepared to deliver a dead baby. It is recognised that the parents may need to hold and grieve their baby. This represents the death of one of their children. The question of whether the infant is born dead or only survives a few moments is of less importance to the parent in their grieving, but may cause great distress to staff. Lethal injections may be administered to the fetus prior to delivery (usually by intracardiac injection of potassium chloride) after obtaining the written consent of the parents. This is largely for the sensitivity of staff.
Techniques
Dilatation and evacuation may be performed up to 18 weeks, using prostaglandins intravaginally to prepare the cervix. This technique is now regarded as safe if performed by experienced staff. However, there is no fetus for the parents to mourn or for pathological examination.
Alternatively, labour may be induced with prostaglandin. This usually takes 12 to 15 hours. It is safe and results in a baby to hold, name, bury and to take momentos. All of these may be very important for the grieving process. It is also possible to carry out a post-mortem examination that may assist with genetic counselling and to develop a database for research.
Disposal of the fetal remains or stillborn infant
First trimester terminations result in very little demonstrable tissue, so there is no infant for the parents to see or hold. The remains are incinerated in the hospital incinerator.
After 16 weeks, the fetus is delivered by induction and after 20 weeks is notified as a stillborn infant. The infant is buried or cremated and this may follow a simple ceremony, including a memorial service in the hospital. Alternatively, the parents may make their own arrangements for their infant.
Emotional reaction of parents
After termination for severe fetal abnormalities, there is grief as for the death of any child. This may be severe and may require careful counselling. The aim is "to help parents reach the stage where they think of their lost child with regret but not pain". Termination for "social" reasons leads to a quite different emotional response, usually marked by relief and often guilt.
8. The Murdoch Institute
Representatives of the Murdoch Institute gave an oral submission.
Most terminations of pregnancy that occur in Victoria are prior to 20 weeks gestation. It was estimated that there might be approximately 50 late term terminations that occur for fetal abnormality. The representatives had no knowledge of late terminations occurring for psychosocial reasons.
The importance of the role of counselling was emphasised as was abiding by the wishes of the mother.
The following were proposed:
a. If it is indicated that a termination of pregnancy is performed, it should be as early as possible thus avoiding the need for a late termination. Terminations should be performed in facilities and utilising procedures that are consistent with best practice.
b. If late term terminations are to be performed, they should be carried out by a first class service. At present, only the public health system is equipped to deal with these. This is because:
c. Specialist ultrasound examination of the fetus at 12 weeks gestation should be available for all pregnant women.
d. In view of the ambiguity in the law concerning termination of pregnancy, a professional body should develop guidelines for good professional and ethical practice in this area.
9. Nurses Board of Victoria
This submission stated the code of ethics and professional conduct that governs the practice of nursing and relates to pregnancy termination. These include:
The submission in concerned that women who have had a spontaneous stillbirth will receive counselling support but this is often not provided to women who have had a termination of pregnancy.
It was also noted that infants born after 23 weeks gestation might be resuscitated and cared for in neonatal units. This situation poses ethical and practice issues for nursing and midwives’ practice.
The ethical dilemma centres on the rights of both the mother and the fetus. The question of informed consent by the women to screening for fetal abnormality was raised, together with the question of informed consent to late termination. Informing the woman of the outcomes of screening tests and the limitations of the tests is important.
The Board considered that there are a number of points that require attention. These included the disposal of the fetus, education of the community, the rights of the fetus, mother and staff, appropriate use of qualified medical and nursing/midwives and the effects on staff and the community, particularly in rural communities.
It was submitted that written information about screening and diagnostic tests for fetal abnormality, prepared by consumer groups, should be available and widely distributed.
10. Psychologists Registration Board of Victoria
This Board did not consider that it was appropriate to make a submission to the working party, considering that it was the province of a professional association.
11. The Royal Australian College of General Practitioners, Victorian Faculty
The College’s submission recognised that there were two main groups of women who may need late term termination. The first were women who were late in recognising that they were pregnant, and the second were women with a wanted pregnancy but an abnormality was detected late in pregnancy, or where there is a severe medical problem for the mother.
The submission focused on how the need for late term termination could be prevented, including the part that general practitioners may play in education and counselling women about contraception, in making an early decision about continuation of pregnancy and the provision of a telephone information service about TOP. In particular, the College submitted that if a woman decides to terminate the pregnancy, this should be available within one week. Although public hospitals have an obligation to provide this service, private clinics should be supported, as this is where the majority of TOP procedures are carried out. It was also stated that complication rates in private clinics are lower than in public hospitals. These comments refer to TOP in general and are not specific to TOPs performed beyond 20 weeks.
Although the submission considered termination at any stage of pregnancy, it stated that in late terminations, women have a choice in the procedure that is to performed: dilatation and evacuation in theatre or induction of labour and delivery of the fetus. This choice is not available in rural areas. It was not stated how often late terminations were carried out in rural areas, but it was stated that they would be carried out by specialists and not by specially trained general practitioners.
The role of general practitioners in counselling was emphasised. There should be communication between the woman’s GP and those performing the termination. The GP’s knowledge of the woman’s family background and belief systems will be important in counselling.
The submission considered the question of antenatal screening for fetal abnormalities, recognising that some tests may not be appropriate until the second trimester, for example, amniocentesis at 15-16 weeks, and the disadvantage for women in rural areas with possible delays and difficult access to investigations and procedures.
12. The Royal Australian College of Obstetricians and Gynaecologists
The RACOG does not have any formal policies or guidelines with regard to pregnancy termination. The College has always taken the view that this is an issue between a doctor and a patient and as such, is not amenable to general guidelines.
13. The Royal Australian and New Zealand College of Psychiatrists
This submission considered the emotional outcome between medical and surgical procedures for late termination. It was noted that although surgical termination results in no fetus that can be viewed, in many cases and in particular, in cases of fetal abnormality, viewing the fetus may not be beneficial and has been shown to intensify the initial grieving with no apparent benefits.
The submission quoted reference to state that there are two crises for a woman who decides to terminate her pregnancy for reasons of fetal abnormality: the first is in the discovery of the abnormality and the second is the termination itself. Both would be expected to have a grief reaction, but the distress may be no greater, and even less, than in women who have had spontaneous loss.
In general however, it was stated that there is a paucity of data on the psychological implications of late term terminations, but that it is likely that grieving will be similar to that of early termination. Sensitive pre- and post- termination counselling and support is important. The most vulnerable group is likely to be those with religious or moral ambivalence to termination in one or both partners.
For women who seek termination late in pregnancy for reasons other than fetal abnormality, it would be important to make a full psychosocial evaluation pre-termination, although there is little research to support any conclusion.
14. Royal Women’s Hospital
The Royal Women’s Hospital provided the Board with a comprehensive and informative submission as well as an oral submission.
The Royal Women’s Hospital provides pregnancy termination services after 20 weeks gestation as part of its public health responsibility to provide safe abortion services to Victorian women and its commitment to excellence in women’s health.
In the twelve months to October 1997, there were 32 terminations of pregnancy beyond 20 weeks gestation performed. This rate has remained stable over the past few years. All the terminations performed in the preceding 12 months were for serious fetal abnormality.
Terminations beyond 20 weeks at the Royal Women’s Hospital are for the following reasons:
In accordance with legislative requirements, every birth after 20 weeks is registered and a death certificate in completed. Information is provided to the Victorian Perinatal Data Collection Unit.
Every case of fetal death after 20 weeks is considered at the monthly Perinatal Mortality Meeting. This is a quality assurance meeting of the Royal Women’s Hospital in which there is peer review of the circumstances and management of each case.
Counselling
The Genetic Counselling service is directly involved in the care of women who seek late termination of pregnancy. The service provides:
Given that most of these pregnancies are wanted and anticipated, the diagnosis of a problem so late in the pregnancy is very distressing for the family and for the health professionals who care for them. The counselling process may involve many sessions exploring the issues and the implications of the termination. In this process, partners are involved in discussions.
The majority of women who are offered pregnancy termination after 20 weeks in the presence of a serious fetal abnormality choose to continue the pregnancy.
If a woman requests a late term termination and is refused in the absence of serious fetal abnormality or life threatening maternal illness, further counselling and follow-up are offered.
Methods of termination of pregnancy
There are two methods of termination that are performed at the Royal Women’s Hospital. It is acknowledged that there is no ideal method and both procedures have a role to play. Factors that determine which method to use include the woman’s preference, the need for a pathological examination and the clinical details of the pregnancy.
Most patients undergoing terminations of pregnancy at the Royal Women’s Hospital are cared for by the mid-trimester service. The Obstetric Unit would manage any inductions over 23 weeks.
Induction of labour
The majority of terminations after 20 weeks at the Royal Women’s Hospital are performed by induction of labour with prostaglandin. These are managed in the delivery suite.
Dilatation and Evacuation
These occur in the operating theatre
Handling of fetal remains and the stillborn infant
All tissues are handled with care and retained, encouraging the parents to decide on the disposal. This may include burial and religious ceremony.
Fetuses born as stillbirth infants may be held, mourned and named by parents.
Photographs, foot and hand-prints may be taken as momentos.
Management of Staff
It is acknowledged that staff who are working in this difficult area need counselling and support. Termination of pregnancy after 20 weeks gestation is distressing for staff. Therefore, staff are encouraged to raise and discuss any concerns about practice issues at team meetings.
The hospital is in the process of appointing a peer support coordinator whose role will include being available to counsel staff and provide support where necessary.
15. Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity
This submission outlined the methods of data collection on all perinatal deaths in Victoria and notes that all death certificates for all stillbirths and neonatal deaths are received by the Council. This includes all births after 20 weeks gestation or over 400 gram, and is regardless of whether the birth is spontaneous or the result of termination. The Council compiles information on terminations for fetal malformations at any stage of pregnancy, and publishes this information in the Annual report. In Victoria, there are no data readily available for terminations of pregnancy when there is no malformation, and there is possibility of under-reporting of some major abnormalities which may be listed a stillborn, induced for obstetric reasons and not stated as for fetal reasons.