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Salient. Victoria University Student Newspaper. Vol. 37, No. 7. April, 17 1974

abortion a fact of life — A Woman Doctor Deals With the Medical Issues Involved

abortion a fact of life

A Woman Doctor Deals With the Medical Issues Involved

(Prepared by Margaret J. Sparrow for the National Women's Abortion Action Conference, held at Victoria University of Wellington, July 14-15 1973).

Although I am a member of a number of organisations, some of them medical and professional, I would like to make it clear that I do not speak for any of them What I present today is a personal viewpoint. It is the viewpoint of a practising doctor with a respect for human life, an interest in the quality of life, and a human-Italian concern for people.

At the outset I must state that what I am going to say is biased. You also have your own particular bias and I think it is helpful that we recognise this and respect each other's values and endeavour to find areas of agreement.

I received virtually no education on abortion during my medical training. I did not lake the trouble to read the Crimes Act 1961 and like the majority of doctors was confused about the law and its interpretation. I found it difficult to discuss abortion with many of my colleagues and even more so with my patients, I ignored the problem for as long as possible. I had an inkling that all was not well. When a patient said. "Well, it you can't help me I'll just have to find someone else", I proffered something about the dangers of illegal abortions, adding quite illogically, "But if you do need help alter an illegal abortion, come back and see me". Fortunately for me some of them did and I was forced into rethinking my position and my whole altitude to abortion. I joined the Abortion Law Reform Association.

I am frequently asked, "Are you for or against abortion"? To me this is a non-question. I am neither. For me abortion is a fact of life, sometimes natural, sometimes necessary and sometimes desirable. And yet people don't ask me, "Are you for or against appendectomy"? It is clear that although abortion may be a medical event it is also something more than that. It is a topic which arouses very deep feelings. It is a complex problem with ethical, social, legal, medical and very personal aspects, none of which can be regarded in isolation. Many individuals feel that they have worked through to a position that they find tolerable, but our society in general has been unable to reach agreement on some of the major issues. There is much argument about what the real issues really are. The only way abortion can appear uncomplicated is to concentrate on one of the issues such as, "When does human life begin"? or the freedom of the individual, or feminist rights, but the complexities of the abortion issue are not readily amenable to this one-dimensional approach.

So we are off to a pretty shaky start. One must also be aware of certain perennial conflicts. There is a great discrepancy between professed attitudes and actual practice e.g. the distraught parent proclaiming, "We don't really believe in abortion doctor but this is our daughter", or the doctor professing the sanctity of human life from the moment of conception, while inserting intrauterine devices. There is also the conflict between reason and emotion, exemplified by the young woman who sincerely believes that abstinence is the best method of contraception, until the morning after. She may also have a conflict between deliberate planning and the page break very human tendency not to plan. The law highlights the conflicts that exist between freedom and control, and the rights of the individual versus those of society.

With such a complex subject and so many areas of conflict abortion is an ideal subject for a crusade and the tactics are familiar. You belittle the opposition, you overstate your own case, you monopolise the discussion, you only marshall those facts which support your argument and you use all the emotive language at your disposal. Everyone has a right to crusade and you may feel very strongly that this is the only way to tackle the problem, but the weakness of this approach is that it very often leads to confusion rather than enlightenment.

I will now concentrate on some of the medical issues that are frequently raised, not because I think that they are the most important, but because this is the area in which I think I have a responsibility to contribute. The so-called medical decisions that doctors make however are ultimately a reflection of their own bias rather than decisions based on purely medical facts. Incontrovertible evidence just does not exist for many of the abortion issues and doctors merely select those papers, scientific articles or opinions which support their own ethical or moral stance.

Such controversial issues are: What are the medical indications for abortion? Physical health? Ectopic pregnancy? Mental health? Congenital deformity?

What are the social indications for abortion? Rape? Incest? Under 16 years? Family circumstances? Premarital conceptions? What are the psychiatric effects of an abortion on the mother? What are the effects of not having an abortion on the mother? On the child? When does human life begin? (Very often discussed).

When does contraception end and abortion begin? (Hardly ever discussed). Who should decide whether to abort or not? The doctor? Two doctors? A committee? The mother? The father? The parents? A social worker? Who and why?

Taking the last question first, I can find no sound reason for assuming that I know better than the patient. I consider it my responsibility to provide her with medical information and to discuss the problem as fully as possible, considering all the alternatives. Each case is different but in general the final decision should rest with the woman.

Papers can be cited to "prove" whatever stance one adopts and even the same paper can be used for different purposes. Take for instance on the topic of psychiatric indications, the Swedish paper by Kirstin Hook. It is a follow-up survey of 249 women refused abortion in Sweden, where the decision rests with a committee. 14% did in fact have an abortion, while 86% continued the pregnancy, 23% were considered to have adjusted to their situation almost immediately, 53% to have achieved adjustment after an initial period of disturbance and 24% were still showing significant disturbance after 18 months. The paper concluded that the mental health of women denied abortion was worse than those granted an abortion. Others however use this paper to point out that the majority adjusted well and emphasise the need for supporting services etc. It convinces them that abortion is not the only course that there are workable alternatives.

"What I present.....is a personal viewpoint. It is the viewpoint of a practising doctor with a respect for human life, an interest in the quality of life, and a humanitarian concern for people."

So what? All this doesn't mean that there are no answers to the questions, but it does mean that the truth is harder to find.

When does human life begin? There is no consensus here. Some say at conception? What does that mean? At fertilisation? At implantation? Some say at quickening, others at the point of viability about 26-28 weeks. Others say at birth. At the first International conference on Abortion in Washington, October 1967 the following statement was issued and is often quoted: "Our group could find no point in time between the union of the sperm and egg and the birth of the child at which point we could not say that this was a human life. The changes occurring between implantation, a 6 week embryo, a 6 month foetus, a week old child and amature adult are merely stages of development and maturation".

Life is a continuum. An ovum is alive. A sperm is a living, moving cell. Both contain 23 chromosomes. When the ovum is released it passes into the Fallopian tube where it may meet living sperm. Fertilisation may occur, probably in the outer part of the tube. This significant event passes unnoticed by the woman and it is undetectable by medical science. The two nuclei of the ovum and the sperm fuse and we now have a single celled zygote with the full complement of 46 chromosomes and a sexual identity, genetically male or female. The zygote travels along the Fallopian tube and 24 hours later the first cell division has taken place. By the third day there are 16 cells and by the fourth, a small cluster called a morula. On about the fifth day this cluster of cells hollows out to form a blastocyst. It has now reached the uterus and on about the sixth or seventh day the process of implantation commences. This process lakes about 4 days to complete. Cell divisions continue apace and the primitive placenta and the primitive embryo develop separately, the life support system being much larger than the embryo proper at this stage. Between the 2nd and 3rd weeks twinning occurs in the case of identical twins. By, the third week the embryo is composed of three layers of cells and is approximately ½mm in length. But let us leave it there and take a closer look at some aspects.

There is a rare condition called a hydatidiform mole which occurs in 1: 2,000 pregnancies. It is an overgrowth of the placenta at the expense of the embryo. It is difficult to argue the rights of the placental tissue versus the embryonic tissue. Both are the product of the fertilised egg. Logic reaches the point of absurdity. Common sense prevails and medically the hydatidiform mole is classified as a pathological entity which is removed as soon as possible.

"....I can find no sound reason for assuming that I know better than the patient."

Other rare tumours such as teratomas, collections of genetically unique human tissue, exist. These cannot be categorised either theologically or legally but only medically. They are removed surgically and treated as any other tumour.

In these cases the law does not intrude into medical practice. Society has confidence in the system of professional ethics, standards and conduct.

Another well known complication of pregnancy occurs when the embryo implants in some ectopic site, usually in the Fallopian tube. About 1:300 pregnancies are affected in this way and on very rare occasions the pregnancy can go to term. There are a few people living in the world who have never been in their mother's womb. However even strict Roman Catholic ethics allow termination of an ectopic pregnancy, sacrificing the potential life of the foetus for that of the mother. Looked at in fine detail even the most monolithic ethical defences have cracks and absolutes are abandoned for statistically based decisions.

Abortion is a fact of life. Many fertilised ova fail to implant. Of those that do, conservative estimates are that 10-15% at least, spontaneously abort. A proportion of these that have been studied have shown an increased number of genetic defects. Abortion is common, natural and in the case of defective genetic material, biologically useful. Should research be promoted into salvaging this natural wastage? Should gene manipulation be encouraged? These are difficult questions to which we must apply ourselves, sooner rather than later.

Advances in medical science have raised new ethical and legal problems. We draw arbitrary lines to serve our social needs but these need reviewing in the light of new knowledge.

Dr Margaret Sparrow

Dr Margaret Sparrow

Where does the "morning-after" pill fit into the scheme of things? High doses of oestrogen prevent implantation of the fertilised ovum, yet we cannot even tell whether an ovum is fertilised or not. We do not fully understand the mechanism of action. Should the use of this method be discouraged? I am inclined to think not and prescribe this medication when it is necessary.

What is the position regarding intrauterine devices? The ovum is fertilised but does not implant because of the presence of the device. Once again we don't fully understand the mechanism of action.

We are entering new fields every year. What of prostaglandins given at the time of a missed or late period to induce menstruation? And the use of menstrual extractors for the same purpose? These are new and valuable methods helping to bridge the gap between foresight contraception and hindsight abortion.

Congenital deformities such as Mongolism (Downs Syndrome) and Rubella raise different problems. Many doctors would support termination when there is a significant risk of producing a serious congenital abnormality, but this is not permitted under our present legislation. I think women and parents generally should have the right to decide whether or not to risk having a seriously malformed child. About 3-5% of babies are born with a major defect, most unsuspected. What are the rights of the handicapped to life? Should they be any less than a normal foetus? Having spent a considerable part of my professional life caring for the handicapped I am aware that even those with a moderately severe handicap still show a zest for life. But I have also seen the immense problems that sometimes accompany a handicap and I believe that parents should have the right not to start on the journey if it seems almost certain that they will have a serious accident on the way.

In the case of Rubella, immunisation of girls before they reach child-bearing age should be encouraged, (and incidentally we have the occasional pregnancy in 11 year olds). If Rubella is contracted in the first 4 weeks of pregnancy there is a 40-60% chance of a major defect and later the risk drops to 15-20%. Is this a sufficient reason to abort?

In the case of Downs Syndrome, foetal cells are required for examination to detect the chromosomal pattern. It is possible to sample these at about 14 weeks gestation but it might be 20 weeks before the diagnosis is made. Because the relatively new science of cytogenetics has not yet made early foetal sampling possible, such cases are necessarily terminated in the mid-trimester.

Pregnancy diagnosis is another problem. Some of you may not realise this. To you it is self-evident. Either a woman is pregnant or she is not. In practice it is often difficult to diagnose an early pregnancy. In a woman with a regular 28 day cycle she will usually be unaware of any change until the missing of her first period, approximately ately 14 days after fertilisation. But there are other causes of delayed periods and most women do not have regular clockwork cycles. If she is in the habit of taking her morning basal temperature she may be able to record a sustained elevation of temperature, one of the first signs of established pregnancy. If the period is delayed for reasons other than pregnancy, menstruation can be induced by giving a combination of oestrogen and progestogen. The most certain and widely used tests of early pregnancy involve the detection of chorionic gonadotrophin or HCG. It is detectable between the 21-25 days of pregnancy and reaches a maximum in the 2nd or 3rd months. Immunological tests have replaced the older biological tests such as the frog test. One such test commonly used by doctors is performed on a slide, using a drop of urine, and the result can be read in two minutes. It is accurate in about 95% cases but there may be false positives or false negatives. The test may be positive within 10 days of the missed period but many doctors do not normally do the test until the period has been delayed by an estimated 14 days because of the large number of false negatives in the early period. There is a mail order service for those who cannot see a doctor. Uterine enlargement cannot be detected with any degree of certainty until 6-8 weeks gestation. Changes in the vaginal and cervical tissues may assist diagnosis as may the presence of breast changes and nausea.

I hope that this has at least demonstrated what a large grey area there is between the two states, pregnant and non-pregnant, between normal and abnormal, and between contraception and abortion. More research is needed into many of these aspects.

With improvements in medical science the discussion we have today may become irrelevant to our daughters. It is often stated that contraception is better than abortion. I say it myself often. But isn't it largely a matter of safety? If a method of early abortion was developed that was safer than any available method of contraception, would you still prefer contraception? Consider the prospect of an absolutely reliable method, which women could use themselves, as often as they liked, with no side effects, so cheap it could be distributed free to all who wanted it, readily available from non-medical sources, and so simple to use that uneducated women could understand the method. Would it matter whether the method was technically an early abortifacient or a strict contraceptive?

WON AAC Newsletter. The Campaign newsletter is produced monthly and carries reports from local Committees on recent activities they have organised. Subscribers are informed on what the Campaign is doing and how they can participate. Overseas news items, relevant quotes from MP's and local news items, plus contributions from subscribers are also included. Subscription rate is $1 for 10 issues. "On Abortion and Abortion Law" by Lucinda Cisler. This excellent and very readable article deals with the question of "reform versus repeal" and discusses the detrimental effects that partial changes can have. The article has been reprinted from a US feminist publication, 'Notes from the 2nd Year' published in 1969. 20c per copy. "The Right to Abortion" by Stella Brown. In this article, published in an anthology on abortion in 1935, the writer puts forth a powerful argument for women's right to choose abortion. It is inspiring to read, since it part of the history of the abortion rights movement, and yet it is still very relevant today. 30c per copy. Help Build WONAACI To: Women's National Abortion Action Campaign P.O. Box 2669 WELLINGTON Please post me the Campaign newsletter. I enclose $1 for 10 issues. Please send me the reprint "On Abortion and Abortion Law". Number of copies (at 20c each)......... Please send me the reprint of "The Right to Abortion". Number of copies (at 30c each)....... I want to be active in the Campaign. Please ring me. I wish to help the Campaign by donating $....... Name.............................................................. Address.....................................Phone.......