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LETTERS TO THE EDITOR J Fam Plann Reprod Health Care: first published as 10.1783/147118907781005038 on 1 July 2007. Downloaded from

Nurses and there were plenty of expressions available which Vincent Argent, FRCOG, LLB Vincent Argent and Lin Pavey have concluded, in would have had that effect. Surgical termination Consultant Obstetrician and Gynaecologist an analysis of the House of Lords case Royal using modern methods was not amongst the (Lead in Sexual Health), Addenbrooke’s College of Nursing v DHSS [1981] 1 AC 800 procedures envisaged, and it was certainly not Cambridge University Teaching Hospital, (“the RCN case”), that without any change in the foreseen or foreseeable that it might be Cambridge, UK. E-mail: [email protected] law, nurses can legally perform surgical induced suggested that nurses might be significant abortion.1 Their article contains some dangerous operators in such procedures. Lin Pavey, RGN legal misconceptions. The dissenting views cannot merely be Member of RCN Nurses Working in Termination The RCN case concerned the participation of discounted. They emphasised, very powerfully, of Network nurses in -induced . The the need for great caution in the construction of House of Lords decided by a majority (3:2) that the statute, and in particular the need for judges to in in certain circumstances nurses could participate. be careful not to usurp the function of Parliament Each minute of every day, nearly 40 women The RCN case decided that for the procedure and engage in judicial legislation. The danger of undergo dangerous, unsafe abortions.1 These that the court was considering: such judicial legislation is particularly acute since unsafe abortions are often performed by unskilled (a) is a process. it is a long time since the was providers or under unhygienic condition or both. (b) The process may be effected by a team. enacted; abortion practice has changed Estimates based on figures for 2000 indicate that (c) Section 1(1) of the Abortion Act 1967 immeasurably since Parliament debated and 19 million unsafe abortions take place each year permits delegation to nurses of some acts voted. and an estimated 681000 women die as which form part of the process. This includes The RCN case draws no distinction in consequences of unsafe abortion, and almost all acts that have a direct effect. principle between medical and surgical abortion. occur in developing countries.2 (d) The process must be initiated by a registered But that does not mean that all acts which are In Nigeria, as is also the case in most medical practitioner, and must be under his done or it is envisaged might be done by nurses developing countries, unsafe abortion has control throughout, in the sense that anything in the performance of surgical abortions fall assumed a serious problem, and done other than by him must be done within the boundaries of appropriate delegation. induced unsafe abortion has been established as pursuant to his instructions. That is the basic error into which Argent and an important contributor to maternal morbidity (e) What amounts to acceptable delegation may Pavey fall. and mortality. In Nigeria, induced abortion is a be determined by “accepted medical So: does the RCN case say that it is lawful criminal offence both for the seeker and the practice”. for nurses to perform surgical abortion? No, it provider. The penalty is 14 and 7 years jail One of the judges in the majority, Lord does not. The position in relation to nurses’ sentences, respectively, for the provider and Keith, expressly regarded the decision as one on involvement in procedures other than that client. These penalties notwithstanding, induced its own facts. He said: “…it remains to consider specifically considered in the RCN case is unsafe abortions are still performed on a daily whether, on the facts of this case the termination wholly unclear. It would be very unsafe for basis both by skilled and unskilled personnel. can properly be regarded as being “by a anyone to act on the basis of the assertions in the There are approximately 610 000 abortions registered medical practitioner”2 [emphasis my Argent and Pavey article. If it is seriously performed in Nigeria annually with an abortion own]. This means that when considering an proposed that nurses should perform surgical rate of 25.4 per 1000; of these, 60% are thought abortion procedure, unless one is dealing with abortions then the matter should be considered to be unsafe.3 In Nigeria, unsafe abortion precisely the procedure that the RCN case again by Parliament. A ruling on the point by any contributes up to 20% of maternal mortality, and considered, it cannot be asserted that a majority court lower than the House of Lords is unlikely those women that survive are faced with of the House of Lords says that the procedure to give an answer sufficiently definitive to lay to complications such as sepsis, vesicovaginal falls within Section 1(1). rest the doubts of those affected by the issue. fistula, anaemia, ruptured (sometimes Although the RCN case is an important ending in hysterectomy), amongst others. statement of the meaning of Section 1(1), it Charles Foster, MA(Cantab), MRCVS Factors associated with this high morbidity leaves some important questions unanswered. Barrister, Outer Temple Chambers, London, UK. and mortality from unsafe It is plain that “accepted medical practice” E-mail: [email protected] include restrictive , activity of itself cannot be the correct test, unless it is to be quacks and untrained providers, poor health- References seeking behaviour of women, poor and read as “medical practice accepted by the courts”. 1 Argent V, Pavey L. Can nurses legally perform surgical The main difficulty with making “accepted induced abortion? J Fam Plann Reprod Health Care inadequate post-abortion care facilities in health medical practice” the touchstone of appropriate 2007; 33: 79–82. institutions, inadequate access to delegation is that the Act itself puts obvious limits 2 Royal College of Nursing v DHSS [1981] 1 AC 800; p. counselling, information and services and poor 835. on the use of that idea. Suppose that it became the 3 Note, for example, Bolitho v City and Hackney Health socioeconomic status of Nigerian women. majority opinion amongst gynaecologists that all Authority [1998] AC 232; also the High Court of This suffering and these deaths are steps in an abortion should be performed by Australia in Rogers v Whitaker (1992) 109 ALR 625. preventable and the solutions are well known, nurses. It would then, in a sense, be “accepted available, practical and cost-effective, but they http://jfprhc.bmj.com/ medical practice” that nurses should perform all Reply are too often neglected because of political and steps. But that would be prohibited by the Act. It Charles Foster’s critique is useful and agrees that social constraints. The abortion law in force in could not be legally accepted medical practice. abortion law should be modernised. The Abortion Nigeria today is still the one adopted from the Medical practice looks to the law to determine Act 1967 does not reflect the realities of current British colonial government of 1861. No what is acceptable, not vice versa.3 Any test that clinical practice and the increasing role of nurses reasonable amendment or modification has requires the law to defer entirely to medical in the provision of abortion care. been made to keep apace with time. The practice in determining the correct construction The statute could be changed but a test case existing abortion law prevents the of the Act must be a wrong test. Although in other in the House of Lords or even a ruling from the institutionalisation of safe abortion practices areas of the law (notably clinical negligence), the Department of Health would suffice. Pro-choice and drives abortion underground, thereby law has great respect for the views of responsible and anti-abortion groups hold opposing views on encouraging the use of quacks and unqualified on September 25, 2021 by guest. Protected copyright. medical practitioners, and is importantly (and how the law should be changed but it is important providers who cause distress and suffering to often decisively) informed by those views, it has that a new approach reflects modern clinical the women concerned. It also restricts long been one of the pillars of medical law that need. counselling and training of health professionals the courts, not the profession, set the standard. If Foster does state that the RCN case draws no on abortion-related issues. that is true of standard setting in the common law, distinction in principle between surgical and Post-abortion care, an unfortunately still more should it be true of statutory medical abortion and this is, in fact, the hub of neglected vital tool of the construction. our argument. In other jurisdictions, nurses and care package for Nigerian women, should be So what must have been meant was “legally other providers are already providing a safe seriously revisited, revitalised and promoted in acceptable” medical practice. On the facts surgical service. This will assume increasing Nigeria as a very important intervention strategy considered in the RCN case, it was found that importance in the UK where the Royal College of to deal with complications arising from unsafe the medical induction procedure was acceptable Obstetricians and Gynaecologists has recognised abortions. Women who have unintended and accordingly fell within the boundaries of s. doctors’ relative disinterest in providing this should have ready access to reliable 1(1). essential service to women. information and compassionate counselling. In If it is legitimate to use accepted (or Foster considers that accepted medical all cases, women should have access to quality acceptable) medical practice as the arbiter of practice should by judged by the courts but we services for the management of complications of legality, it is strongly arguable that the relevant know that sensible judges do take a pragmatic abortion. Where the law permits, there should be medical practice for the purposes of determining view based on medical expert opinion. provision of quality standards for abortion legality is the practice known about or envisaged The Abortion Act was designed to remove providers. by Parliament at the time of the enactment. As the mischief of unsafe abortion and it is now clear The 1994 International Conference on Lord Denning pointed out in the Court of that a safe service can be run by nurses who are Population and Development in Cairo, Egypt, at Appeal, had Parliament intended to make the part of a team under the overall supervision of a which Nigeria was a participant, agreed that in standard move with shifting medical practice, medical practitioner. order to reduce the morbidity and mortality from

©FFPRHC J Fam Plann Reprod Health Care 2007: 33(3) 221 Letters to the editor J Fam Plann Reprod Health Care: first published as 10.1783/147118907781005038 on 1 July 2007. Downloaded from unsafe abortion, improved and expanded family third-generation progestogens. A 1996 study by Cytology sampling using brushes planning services must be given the highest Saure et al.2 was a randomised double-blind I write in response to the letter from Dr Leng priority. Twelve years after the Cairo conference, multicentre study of 310 women, comparing the Neoh in the April 2007 issue of the Journal.1 the contraceptive prevalence in Nigeria is 7.3%.5 effects of two sequential HRT preparations, As an experienced cervical sample taker I This is worse for adolescents and unmarried containing either estradiol and norethisterone, or agree with Dr Neoh that when sampling the women who are frequently excluded from estradiol and desogestrel. Both regimes using the Cervex-Brush® caution is contraceptive services. In many developing successfully alleviated menopausal symptoms, required when the client has an intrauterine countries, lack of information on sexuality and and there was no significant difference in device or intrauterine system (IUD/IUS) in situ to contraception targeted at the adolescent bleeding patterns with the two combinations. ensure the clinician does not inadvertently population has often translated into a high There was no endometrial hyperplasia or atypia remove the IUD during sampling. prevalence of unwanted pregnancy. Thus, there is identified during the study. However, I must point out that the plastic great need for the establishment of accessible and My own view is that using Cerazette as the fronds of the brush are bevelled for clockwise affordable youth-friendly centres, different from progestogen part of HRT should be acceptable rotation only.2 The Cervex-Brush should be a hospital setting, where these vulnerable groups practice. However, women of perimenopausal rotated five times in a clockwise direction and can go for care. Such centres should be equipped age do have much reduced fertility, and some not, as stated by Dr Neoh, “five times clockwise to offer services on family planning counselling would say that Cerazette, whilst it offers an and five times anti-clockwise”. This is incorrect and information, education on reproductive additional choice of POP, could be regarded as sampling and there is also more risk of the physiology and overall safer sex, and should be ‘contraceptive overkill’. We cannot, however, get threads becoming tangled. able to provide post-abortion care services. Also, away from the fact that the 12-hour rule for daily When presented with the above situation, my regulations, policies and/or laws that restrict administration with Cerazette makes it practice is to rotate the Cervex-Brush five times adolescents’ access to such services should be considerably easier to take. in a clockwise direction, but to do it in two stages, revised. The question remains as to whether namely after rotating twice, stop, remove the In conclusion, the contribution of unsafe Implanon® could be used as part of an HRT brush from the cervix (but not from the vagina) abortion to maternal mortality will be drastically regime. I feel it is unlikely this would be the case, and from any threads that may be starting to reduced – if not completely eliminated – if but would be interested in readers’ views on this become entangled, and then continue sampling to specific and goal-directed actions are taken. Such subject. complete the five rotations, ensuring the brush is actions include promoting women’s rights, status repositioned at the same point on the cervix and health; ensuring access to contraception; Deborah J Lee, MFFP, MRCGP where the second rotation finished. I have found providing post-abortion care services, including Associate Specialist in Reproductive Health, that although the threads may start to become counselling; putting referral systems in place; Lead for Medical Education and Training, entangled, it is easy to remove the brush from decriminalising abortion and changing laws Lead for Unplanned Pregnancy, Southampton them without dislodging the IUD. where they are restrictive. All relevant agencies Contraception & Sexual Health Service, Using a Spencer Wells forceps as suggested are called upon to initiate authentic programmes The Quay to Health, Southampton, UK. by Dr Neoh is also an option but this requires that will curb this carnage from unsafe abortion E-mail: [email protected] some skill and may dislodge the IUD/IUS by the as part of the overall strategy for achieving the traction on the threads. This also necessitates millennium development goal, not only in References having a ready supply of instruments. 1 Cerazette Summary of Product Characteristics. Nigeria but also in most developing countries of http://emc.medicines.org.uk [Accessed 27 April 2007]. the world. 2 Saure A, Hirvonene E, Milsom I, Christensen A, Suzanne Jones, RGN Damber MG. A randomised, double blind, multicentre Lead Nurse, Abacus Clinics, Liverpool, UK. study comparing the clinical effects of two sequential MBBS, FWACS Perpetus Chudi Ibekwe, estradiol-progestin combinations containing either E-mail: [email protected] Department of Obstetrics and Gynaecology, desogestrel or norethisterone acetate in climacteric Ebonyi State University Teaching Hospital, women with estrogen deficiency symptoms. Maturitas References 1996; 24(1–2); 111–118. 1 Neoh L. Cytology sampling using brushes [Letter]. Abakaliki, Nigeria. J Fam Plann Reprod Health Care 2007; 33: 135. E-mail: drogoperps@ yahoo.com 2 National Health Service Cancer Screening Cytology sampling using brushes Programme (NHSCSP). Taking Samples for Cervical References I read with interest the letter from Dr Leng Neoh Screening, A Resource Pack for Trainers. NHSCSP 1 World Health Organization (WHO). Safe Abortion: in the April 2007 issue of the Journal.1 Publication No 23. Department of Health (April 2006). Technical and Policy Guidance for Health Systems. Geneva, Switzerland: WHO, 2003. I would like to question the technique of 2 World Health Organization (WHO). Unsafe Abortion: collecting a cervical cytology sample using the Increase in IUD expulsions Global and Regional Estimates of Incidence of Unsafe new liquid-based cytology (LBC) Cervex- It was with great interest, and a sense of déja-vu, Abortion and Associated Mortality in 2000 (4th edn). Brush® described by the author. The National that I read the recent correspondence concerning Geneva, Switzerland: WHO, 2004. Health Service Cervical Screening Programme insertion problems with TT380 Slimline.1–3 3 Henshaw SK, Singh S, Oye-Adeniran BA, Adewole IF, 4 Iwere N, Cuca YP. The incidence of induced abortion (NHSCSP) guidance2 on taking samples for LBC Reading Dr Yadava’s original letter in 1996 http://jfprhc.bmj.com/ in Nigeria. Int Fam Plann Perspect 1999; 24: 156–164. recommends that the Cervex brush is rotated five enabled me to identify the cause of the problems 4 Adefuye PO, Sule-odu AO, Olatunji AO, Lamina MA, that I had been experiencing with insertion, and Oladapo OT. Maternal deaths from induced abortions. times at the external cervical os ‘clockwise Trop J Obstet Gynaecol 2003; 20: 101–104. only’. Perhaps the technique described by the following my adoption of his modification 5 Oye-Adeniran BA, Adewole IF, Odeyemi KA, Ekanem author that involves rotating the brush at the (cutting the introducer tube shorter) I experienced EE, Umoh AV. Contraceptive prevalence among young no further problems. . J Obstet Gynaecol 2005; 25: cervical os five times clockwise and anti- 182–185. clockwise may have inadvertently caused It was unfortunate that the manufacturer (in downward traction on the threads of the this country at least2,3,5) was unwilling to modify Cerazette and HRT leading to its ‘unintentional the device, and that the apparent design problem A general practitioner (GP) wrote into our service removal’. I do not see any benefit in using a has been passed on to newer devices. ® Spencer Wells forceps as suggested by the author In the light of this new evidence, I would like on September 25, 2021 by guest. Protected copyright. recently to ask if Cerazette could be used as the 6 progestogen part of hormone replacement to minimise this risk. In fact, I wonder how one to reiterate my suggestion that it might be therapy (HRT). I would be interested in the views could rotate the Cervex brush with the Spencer appropriate for the Faculty to take up the matter of other Faculty members about this. Wells forceps near the external cervical os and with the manufacturer. The progestogen-only pill (POP) has been that this technique may be a potential cause for used traditionally as part of HRT regimes, inadequate sampling of the cervix. Robert J T Jarvis, MFFP although is not licensed for this indication. It has I would appreciate readers’ comments. General Practitioner, The Surgery, Ludham, always been postulated that from the perspective Norfolk, UK. E-mail: [email protected] of contraception, as the additional oestrogen in Anagha A Nadgir, MRCOG, MFFP References the HRT, might ‘undo’ the mucus thickening Associate Specialist, Contraception and Sexual 1 Hawkins F, Callander F. Increase in IUD expulsions [Letter]. J Fam Plann Reprod Health Care 2006; 32: effect of the POP, that when used as part of HRT Health Service, Middlesbrough PCT, North 267. the dose of POP should be doubled (or trebled). Ormesby, Middlesborough, UK. 2 Yadava RP. Increase in IUD expulsions [Letter]. J Fam As the newer POP, Cerazette works by E-mail: [email protected] Plann Reprod Health Care 2007; 33: 65–66. 3 Yadava RP. Increase in IUD expulsions [Letter]. J Fam inhibiting ovulation1 in almost all cases, this Plann Reprod Health Care 2007; 33: 133. should not be the case with Cerazette as part of References 4 Yadava RP. Ortho Gynae T380S Slimline fitting made 1 Neoh L. Cytology sampling using brushes [Letter]. easier? [Letter]. Br J Fam Plann 1995; 21: 78. an HRT regime. J Fam Plann Reprod Health Care 2007; 33: 135 5 Homouda K. The effect of intrauterine device position In addition, I believe there have been studies 2 NHS Cancer Screening Programmes. Training in and performance of a modified TCu380A insertion of desogestrel as part of the HRT regime, but Taking Samples for Liquid Based Cytology (LBC technique. Eur J Contracept Reprod Health Care Implementation Guide No. 4 Version 1, May 2004). 2002; 7: 31–35. these were halted as a result of the 1995 pill scare http://www.cancerscreening.nhs.uk/cervical/lbc04.pdf 6 Jarvis RJT. Ortho Gynae T Slimline fitting [Letter]. Br J and the venous thromboembolism issue with [Accessed 27 April 2007]. Fam Plann 1996; 22: 107.

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