Late termination of pregnancy: a comparison of ... - Wiley Online Library

General obstetrics

DOI: 10.1111/j.1471-0528.2009.02228.x www.bjog.org

Late termination of pregnancy: a comparison of obstetricians’ experience in eight European countries M Habiba,a M Da Fre`,b DJ Taylor,a C Arnaud,c O Bleker,d G Lingman,e MM Gomez,f P Gratia,g W Heyl,h C Viafora,i the EUROBS Study Group a Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK b Unit of Epidemiology, Regional Health Agency of Tuscany, Florence, Italy c UMR INSERM U558, Paul Sabatier University, Toulouse cedex, Toulouse, France d Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands e Department of Obstetrics & Gynecology, University of Lund, Lund, Sweden f Fundacioń Instituto de Investigacioń en Servicios Sanitarios, Valencia, Spain g Department of Gynecology and Obstetrics, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg h Department of Obstetrics & Gynecology, Klinikum Ludwigsburg, Ludwigsburg, Germany i Department of Philosophy, University of Padova, Padova, Italy Correspondence: Dr M Habiba, Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester, Robert Kilpatrick Building, Leicester Royal Infirmary – PO Box 65, Leicester LE2 7LX, UK. Email [email protected]

Accepted 8 April 2009. Published Online 3 June 2009.

Objective To compare the experience and attitude of obstetricians in Europe towards late termination of pregnancy and the factors affecting their responses.

Main outcome measure Obstetricians’ experience of late

Design Cluster sampling cross-sectional survey. All neonatal

participated (response rates 70 and 77% respectively). The most common indications for late termination were congenital anomalies and women’s physical health. Feticide was not common except in France, Luxembourg and the UK. Active euthanasia of a liveborn was practiced in France and the Netherlands. Obstetricians in Germany were more likely to feel that late termination should be more severely restricted, the opposite was true in Spain and the Netherlands. In Italy, there was dissatisfaction with current status, but opinion was divided, reflecting views on both sides of the debate.

intensive care unit (NICU)-associated maternity units were recruited (census sampling) in Luxembourg, the Netherlands and Sweden. In France, Germany, Italy, Spain and the UK, units were selected at random. In every recruited unit, all obstetricians with at least 6 months’ experience were invited to participate. Setting NICU-associated maternity units in eight European

countries. Population Obstetricians with at least 6 months’ clinical

experience. Methods An anonymous, self-administered questionnaire was

used. Multinomial logistic analysis was used to identify factors predicting the obstetricians’ views about modifying the law governing late termination in their country.

termination of pregnancy and views about national policies. Results One hundred and five units and 1530 obstetricians

Conclusions This research outlines current practice in a difficult and sensitive area and suggests the need for more discussion and support for all those who were involved. Keywords Late abortion, termination of pregnancy.

Please cite this paper as: Habiba M, Da Fre` M, Taylor D, Arnaud C, Bleker O, Lingman G, Gomez M, Gratia P, Heyl W, Viafora C, the EUROBS Study Group. Late termination of pregnancy: a comparison of obstetricians’ experience in eight European countries. BJOG 2009;116:1340–1349.

Introduction Late termination of pregnancy continues to raise considerable ethical debate.1–4 Currently, there is no gestational age distinction between early and late termination, but medical and ethical difficulties increase with advancing gestation. Prenatal diagnosis of fetal abnormalities can occur close to or past the limit of viability, creating additional dilemmas.

1340

Practice in this area is influenced by parents’ and providers’ attitudes and is subject to legislation, which varies between countries. In most western countries, the law allows for pregnancy termination under certain conditions. Late termination accounts for a small proportion of abortions and the majority are carried out following prenatal diagnosis of anomalies. In England and Wales during 2006, only 1.5% of terminations of pregnancy were carried

ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

Obstetricians’ experience of late termination of pregnancy

out at 20 or more weeks of pregnancy.5 Vaydeyar et al.6 in 2005, reported 13 cases performed beyond 22 weeks gestation in the North Western Region of England in 6 years, three of these were beyond 24 weeks. Opinion varies as to which conditions warrant late termination. The most commonly cited indications are aneuploidy, anencephaly, hydrocephalus, multiple anomalies and cardiac malformations. Most late terminations occur in wanted pregnancies. As anomalies may not be immediately fatal, such terminations can result in a live birth. This creates additional dilemmas once the newborn acquires an independent status. Whether an individual clinician agrees to perform late termination of pregnancy is also subject to ethical constraints and to his/her moral stance. For example, it is estimated that up to 90% of gynaecologists in some regions in the South of Italy are conscientious objectors, but the figure is only 10% among UK obstetricians.7 It is unclear, however, how this impacts on late termination for fetal anomalies. Feticide is advocated before late terminations for anomalies that are not immediately lethal, to avoid additional trauma to the woman and staff and also to avert legal uncertainties.6,8–10 On the other hand, the Nuffield Council on Bioethics opined that there is no legal obligation to preserve the life of a newborn with such serious abnormalities as this may be against his or her best interest.11 This may offer some opportunity for late termination for women who decline feticide, but it leaves open the possibility that neonatologists may institute treatment for babies born with non-fatal conditions.11 Eight European countries took part in the EUROBS project (Developments of Perinatal Technology and Ethical Decision-Making during Pregnancy and Birth: the Obstetricians’ Perspective in 2001–2002): France, Germany, Italy, Luxembourg, the Netherlands, Spain, Sweden and the UK as previously reported.12,13 This part of the study was conducted to examine the experience and attitudes of obstetricians in eight European countries of late termination of pregnancy and to explore the factors that influence their attitudes. Data presented here are a subset of a larger study addressing various aspects of perinatal care (see below).

Methods Sample and data collection In each country, only maternity units associated with a third level Neonatal Intensive Care Unit (NICU) were sampled. In Luxembourg, the Netherlands and Sweden, all the existing NICU-associated maternity units were recruited (census sampling); whereas in France, Germany, Italy, Spain and the UK, random samples were selected stratified by geographical area. In all units, all obstetricians with at least 6 months’ experience in obstetrics were invited to participate.

A structured questionnaire was used to survey obstetricians’ practices and attitudes in six major areas: prenatal ultrasound examination; late termination of pregnancy; management of severe prematurity; situations of conflicting opinions between staff and the women; and legal concerns in obstetric practice. The questionnaire was anonymous and self-administered to protect confidentiality; thus, nonresponders were not identified and no reminders were sent.

Statistical analysis Questionnaire coding and data entry were undertaken at the coordinating centre in Italy. Statistical analysis was carried out with the STATA statistical package (version 10.0; StataCorp LP, College Station, TX, USA). Weights, computed as the inverse of the probability for a given maternity unit to be selected within a certain country and geographical stratum, were applied to take into account the different sampling fractions adopted in the participating countries.14–16 Standard errors were adjusted for intra-cluster correlation that is the non-independence of observations within the same maternity unit.16 Unless stated otherwise, results are presented as weighted proportions and 95% confidence intervals (CI). Multinomial logistic regression analysis was used to explore factors associated with respondents’ agreement that termination of pregnancy after 23 weeks should be more or less severely restricted than it currently is. The doctor-related variables considered in the model were: age, gender, having had children, religious background and religiousness, length of experience in obstetrics, involvement in private practice, involvement in research and having performed antenatal ultrasound examinations routinely for more than 2 years. The unit-related variables included: whether the hospital and/or the unit were University-affiliated; and whether the unit was a referral centre for high-risk pregnancies. The final model retained the variables associated significantly with the outcome of interest at the 0.05 level.

Results Participants One hundred and forty-nine units were invited to participate in the study and 105 agreed, corresponding to a unit response rate of 70%. The numbers and proportions of responding obstetricians per country and their sociodemographic and professional characteristics are presented in Table 1. Completed questionnaires were returned from 1530 obstetricians, with an overall staff response rate of 77% (ranging from 63% in Germany to 93% in France). In every country except Italy, France and Luxembourg, about half of respondents were female. In Italy and Sweden, 40% of responders were aged 50 years or more, compared with only 7% of those in the UK. Most responders in Italy,


1341

Habiba et al.

Table 1. Socio-demographic and professional characteristics of responding obstetricians (unweighted proportions), n (%) Italy Number of responders (response rate) 383 (90) Gender Male 241 (64) Female 133 (36) Age (years) Under 30 35 (9) 30–39 67 (18) 40–49 124 (33) 50 and over 149 (40) Having had children Yes 264 (70) No 111 (30) Religious background None 7 (2) Roman catholic 365 (97) Protestant 1 (0.3) Other 2 (0.5) Importance of religion in one’s life Extremely important 64 (17) Fairly important 174 (47) Not very important 81 (22) Not at all important 51 (14) Professional position Unit head/adjunct head 87 (23) Specialist 226 (60) Trainee 64 (17) Hospital appointment Full-time 329 (86) Part-time 52 (14) >2 years of routine antenatal ultrasound practice Yes 169 (44) No 214 (56)

Spain

France

Germany

the Netherlands

Luxembourg

UK

Sweden

328 (80)

100 (93)

139 (63)

126 (74)

15 (79)

163 (65)

276 (74)

169 (52) 155 (48)

63 (63) 37 (37)

71 (51) 68 (49)

64 (51) 61 (49)

10 (67) 5 (33)

84 (52) 76 (47)

127 (46) 147 (54)

68 103 78 75

17 46 22 15

24 73 23 19

10 65 27 23

18 85 45 12

3 60 102 109

(21) (32) (24) (23)

(17) (46) (22) (15)

(17) (53) (17) (14)

(8) (52) (22) (18)

2 5 6 2

(13) (33) (40) (13)

9 (60) 6 (40)

(11) (53) (28) (7)

102 (64) 58 (36)

(1) (22) (37) (40)

195 (60) 128 (40)

71 (71) 29 (29)

58 (42) 81 (58)

80 (64) 45 (36)

249 (91) 25 (9)

8 311 1 4

(2) (96) (0.3) (1)

15 70 3 12

(15) (70) (3) (12)

20 58 59 2

(14) (42) (42) (1)

35 49 37 4

(28) (39) (30) (3)

2 (13) 12 (80) 1 (7) 0

18 27 60 54

(11) (17) (38) (34)

40 7 222 5

(15) (3) (81) (2)

33 119 128 42

(10) (37) (40) (13)

6 25 38 31

(6) (25) (38) (31)

7 64 39 22

(5) (48) (30) (17)

5 15 62 43

(4) (12) (50) (34)

0 3 (20) 8 (53) 4 (27)

34 58 25 38

(22) (37) (16) (25)

24 41 97 101

(9) (16) (37) (38)

43 (13) 199 (61) 86 (26)

18 (18) 58 (59) 23 (23)

25 (18) 47 (35) 64 (47)

10 (8) 59 (47) 56 (45)

1 (7) 10 (71) 3 (21)

10 (6) 65 (40) 87 (54)

26 (9) 212 (77) 37 (13)

288 (88) 40 (12)

97 (97) 3 (3)

130 (94) 8 (6)

109 (87) 17 (13)

6 (40) 9 (60)

149 (92) 13 (8)

246 (89) 29 (11)

113 (35) 214 (65)

47 (47) 53 (53)

73 (53) 66 (47)

63 (50) 62 (50)

9 (64) 5 (36)

68 (42) 95 (58)

128 (47) 147 (53)

Spain, Luxembourg and France were Roman Catholic, whereas in Sweden and the UK, the majority were protestant. In the UK, a substantial proportion (34%) of responders were from other religions including 20% Hindu, 9% Moslem, 1% Jewish. Religion was extremely important or important to more than half of the participants in Italy, the UK and Germany and in just under half in Spain.

bourg (77%) and Italy (67%). The woman’s physical health was cited by 52% of responders in the Netherlands, 51% in France and 47% in the UK; whereas protection of the woman’s mental health was cited by the 49% of responders from Italy. Feticide was not commonly performed except in France, Luxembourg and the UK. The most commonly used method was potassium chloride administration.

The fetus Attitude to late termination of pregnancy Table 2 shows the attitudes on late therapeutic termination of pregnancy after 23 completed weeks. The highest percentage of respondent, who did not induce or assist in late termination over the preceding 3 years, was in Sweden (84%) and Spain (69%) and the lowest percentage was in France (7%). The most commonly cited indication for late termination of pregnancy was fetal abnormality. Down syndrome was most commonly cited in France (89%), Luxem-

1342

Table 3 shows attitudes and opinions in case of a liveborn fetus following late therapeutic termination of pregnancy. Almost half of the respondents have encountered this situation. The most common course of action was to alert the neonatologist in Italy (93%), Germany (78%) and Sweden (65%) or to keep the newborn in a warm environment till death in the Netherlands (74%), the UK (58%) and Luxembourg (50%). Active euthanasia was reported in France (80% of responders having encountered a live birth) and



Table 2. The number of responders who performed late (after 23 completed weeks) therapeutic abortion over the preceding 3 years and their indication (weighted proportions and 95% confidence intervals) Italy

Spain

France

Germany

the Netherlands

Luxembourg

UK

Sweden

In the last three years, have you ever induced OR assisted ‘late’ therapeutic abortions (after 23 completed weeks)?* Induced 13 (8–20) 17 (12–25) 66 (53–77) 39 (27–52) 44 (32–57) 67 (47–82) 58 (49–67) 9 (5–15) Assisted 52 (43–62) 21 (13–32) 81 (69–89) 53 (36–69) 44 (31–57) 60 (38–78) 51 (43–58) 14 (9–21) Neither induced or 40 (31–50) 69 (58–78) 7 (4–13) 41 (26–58) 44 (30–60) 13 (8–22) 35 (27–44) 84 (77–89) assisted Which were indication(s) for the abortion(s) after 23 completed weeks? (more than one answer possible)** Fetal congenital 89 (85–93) 79 (65–88) 96 (89–98) 77 (58–89) 94 (84–98) 92 (86–96) 99 (93–99) 86 (77–92) malformation(s) Down syndrome 67 (58–76) 37 (24–51) 89 (79–95) 36 (31–42) 17 (10–29) 77 (57–89) 50 (42–59) 23 (14–37) Other genetic disorders 54 (45–63) 44 (34–55) 89 (78–95) 68 (52–80) 62 (54–70) 77 (60–88) 69 (61–75) 63 (48–75) Prenatal infection 22 (16–30) 37 (24–52) 46 (39–52) 38 (22–57) 12 (6–22) 8 (4–14) 30 (23–40) 16 (10–26) To protect the woman’s 24 (16–35) 37 (23–52) 51 (36–66) 34 (20–51) 52 (39–65) 8 (4–14) 47 (36–58) 28 (17–43) physical health To protect the woman’s 49 (37–61) 9 (4–18) 27 (12–50) 19 (15–25) 6 (3–12) 0 10 (7–15) 12 (2–44) mental health Social reasons 12 (7–20) 2 (0.6–8) 12 (5–25) 2 (1–4) 6 (2–18) 8 (0.2–76) 3 (0.8–10) 9 (4–18) Other 0.5 (0.1–2) 3 (0.7–15) 4 (1–15) 6 (2–19) 1 (0.3–8) 0 2 (0.6–6) 7 (2–22) In case of a fetus which might survive the abortion procedure, do you adopt any measure to ensure fetal death before expulsion or extraction from the uterus? (more than one answer possible)** Intra-amniotic injection of 0.3 (0.04–2) 13 (5–30) 7 (3–13) 2 (0.3–14) 7 (3–17) 25 (12–45) 12 (6–20) 10 (4–21) hypertonic solution Administration of KCl to 5 (1–15) 3 (1–9) 88 (80–93) 7 (3–14) 28 (13–52) 83 (69–92) 67 (56–77) 2 (0.3–16) the fetus Mechanical compression 0.2 (0.02–1) 1 (0.1–7) 1 (0.2–7) 4 (0.7–18) 10 (5–22) 8 (4–16) 4 (2–9) 7 (2–22) of the umbilical cord Other 0 7 (2–23) 2 (0.6–8) 2 (0.3–7) 5 (1–15) 0 8 (4–16) 0 *Items ‘Induced’ and ‘Assisted’ are not mutually exclusive. **Proportions computed among responders having induced or assisted late therapeutic abortions in the preceding three years.

the Netherlands (26%) but hardly ever elsewhere, and the practice had little support beyond the countries where it was practised. The most favoured option in cases of a live newborn was no resuscitation and nursing care only. There was little support for life saving attempts except in Italy, where a significant minority (35%) were in favour.

Counselling Issues that were commonly discussed with the woman before late termination of pregnancy include, in most countries, the method to be used to terminate the pregnancy, maternal analgesia, duration of the procedure, possible unwanted adverse effects, consent for postmortem examination and availability of psychological support. Practical issues, such as the possibility of seeing the fetus after the procedure, disposal of the body and funeral arrangements, were also frequently discussed in every country except Italy and, to a lesser extent, Spain. The issues discussed least frequently with women were the possibility that the fetus may survive the procedure and the possibility of feticide (Table 4).

Attitudes towards current policies Figure 1 shows the response to a question directed to all participants, asking whether they ‘would support a policy of late termination of pregnancy different from the one currently in force in their country’. Obstetricians in Italy, Spain and Germany seemed to be the least satisfied with current status. Half of Italian and 36% of German obstetricians would support a more restrictive policy, while in Spain, over a quarter of obstetricians would prefer less restriction. Sweden, followed by Germany, had the lowest proportion of obstetricians who would support a more liberal policy. Multinomial logistic analysis was used to explore factors associated with obstetricians’ opinion that termination of pregnancy after 23 weeks should be either more or less severely restricted compared to current practice (Table 5). We used France as reference country as it hosted the highest proportion of responders satisfied with current policy (apart from Luxembourg, which was represented by one Unit). The resulting risk ratios and 95% confidence intervals indicate the likelihood that responders would support


1343

Habiba et al.

Table 3. Live born foetus following late therapeutic abortion (weighted proportion and 95% confidence intervals) Italy

Spain

France

Germany

the Netherlands

Luxembourg

UK

Sweden

Have you ever encountered the situation of a live born foetus following induced late therapeutic abortion?* Yes 54 (42–66) 40 (30–51) 55 (48–61) 44 (27–62) 57 (44–69) 31 (16–52) 42 (32–53) 45 (30–62) If yes, what did you do? (more than one answer possible)** Warn environment only 10 (6–16) 45 (28–63) 4 (1–14) 62 (47–75) 74 (66–81) 50 58 (43–72) 35 (27–44) Neonatologist was alerted 93 (87–96) 45 (33–58) 18 (8–36) 78 (42–95) 49 (33–65) 0 56 (31–78) 65 (28–90) and made decision Administration of drugs 0 0 80 (72–87) 0.9 (0.1–7) 26 (18–35) 25 0 0 to end life Other 5 (2–12) 20 (11–35) 10 (4–22) 7 (2–23) 10 (3–29) 25 7 (2–24) 5 (0.6–33) In general, what do you think should be done in case of a liveborn foetus from abortion performed after 23 completed weeks?* Resuscitation and 35 (24–47) 9 (4–20) 0 8 (3–21) 0 0 3 (0.6–13) 14 (6–27) admission to NICU for life saving treatment No resuscitation and 39 (30–48) 43 (35–51) 9 (5–16) 64 (44–80) 34 (25–45) 31 (20–44) 71 (59–81) 48 (35–61) nursing care only Administration of drug 1 (0.5–4) 6 (2–14) 60 (50–69) 0.4 (0.1–3) 31 (20–46) 38 (32–46) 3 (0.8–10) 5 (1–17) to end life Depends on the baby’s 10 (7–16) 19 (15–23) 14 (9–23) 17 (8–31) 19 (11–29) 15 (8–27) 12 (6–21) 16 (8–28) condition Don’t know 10 (7–14) 18 (11–28) 10 (3–26) 4 (0.7–17) 1 (0.3–8) 15 (8–27) 6 (2–15) 11 (5–22) *Proportions computed among responders having induced or assisted late therapeutic abortions in the preceding three years. **Proportions computed among responders having encountered the situation of a live born foetus following induced late therapeutic abortion.

Table 4. Responses to the question: Before performing or assisting a late therapeutic abortion what do you routinely talk about with the woman? More than one answer may be given. Responses given as weighted proportion and 95% confidence intervals of those who have induced or assisted late therapeutic abortions in the preceding 3 years

The method which will be used Type of maternal anaesthesia/ analgesia Duration of the procedure Possible unwanted adverse effects Possibility that the fetus may survive the abortion procedure Possibility of feticide Possibility of seeing the fetus after the abortion When medically indicated, authorisation for post-mortem examination Disposal of the body and/or funeral arrangements Possibility of psychological support for the woman Other

1344

Italy

Spain

France

Germany

the Netherlands

Luxembourg

82 (75–87) 59 (51–67)

86 (76–92) 81 (70–88)

98 (92–99) 96 (90–98)

95 (89–98) 90 (81–95)

100 100

100 100

63 (54–71) 57 (48–65)

72 (63–80) 71 (62–79)

85 (73–92) 52 (42–61)

95 (81–99) 87 (71–95)

99 (88–99.8) 88 (79–94)

43 (34–52)

19 (13–27)

14 (7–25)

79 (65–88)

8 (5–12) 17 (12–23)

8 (5–14) 29 (17–45)

70 (55–82) 94 (88–97)

59 (48–69)

88 (77–94)

29 (19–41) 53 (44–62) 0.9 (0.2–4)

UK

Sweden

98 (94–99) 97 (93–99)

95 (83–99) 93 (78–98)

92 (24–99.8) 69 (56–80)

93 (89–96) 91 (82–96)

88 (79–94) 84 (77–89)

83 (70–90)

15 (8–27)

57 (40–73)

37 (15–66)

31 (18–49) 91 (83–96)

20 (13–30) 99 (90–99.8)

38 (19–63) 92 (24–99.8)

81 (74–86) 90 (81–96)

7 (3–15) 79 (57–92)

96 (92–98)

90 (79–96)

96 (87–99)

96 (88–99)

86 (71–94)

53 (42–64)

69 (56–79)

87 (73–94)

91 (83–96)

71 (53–85)

84 (71–91)

57 (47–66)

97 (88–99)

70 (58–80)

90 (79–95)

82 (71–89)

95 (85–99)

2 (0.6–9)

5 (2–15)

0

9 (4–16)

100

85 (73–92) 100 0

5 (2–11)

0



100% 90%

No change of current policy Abortion after 23 weeks should be more severely restricted Abortion after 23 weeks should be less severely restricted

80% 70% 60% 50% 40% 30% 20% 10% 0%

Italy

Spain

France

Germany Netherlands Luxembourg

UK

Sweden

Figure 1. The proportion of responders who would support either no change, more severe restriction or less severe restriction of the late abortion policy in their country (weighted proportions and 95% confidence intervals). This question was asked to all obstetricians, independently from their experience of late termination of pregnancy.

Table 5. Factors associated with obstetricians’ opinion that abortions after 23 weeks should be more severely restricted than they currently are Abortions after 23 weeks should be more severely restricted than they currently are vs. no change RR* (95% CI)

Abortions after 23 weeks should be less severely restricted than they currently are vs. no change RR* (95% CI)

Country France 1.0 1.0 Germany 3.7 (1.4–9.6) 1.0 (0.3–3.7) Italy 6.5 (2.6–16.6) 4.3 (1.4–13.1) Luxembourg 0.5 (0.2–1.5) 1.2 (0.3–4.6) the Netherlands 0.7 (0.2–2.0) 3.7 (1.1–12.5) Spain 1.7 (0.6–4.4) 10.1 (3.6–28.5) Sweden 1.4 (0.6–3.4) 0.6 (0.2–1.9) UK 1.5 (0.6–3.6) 1.1 (0.3–4.0) Gender No children Having children No children Male 1.0 1.0 1.0 Female 0.6 (0.4–1.1) 1.5 (1.1–2.2) 0.5 (0.1–1.9) Age 2 years No 1.0 1.0 Yes 1.0 (0.8–1.4) 1.9 (1.3–3.0)

P value**

2 years almost doubled the probability of supporting a more severely restrictive policy (RR 1.9, 95% CI 1.3–3.0). The effect of religiousness, defined as the importance attributed to religion in one’s life, was also noted: feeling that religion was ‘not at all’ important decreased the probability of support significantly for a more restrictive policy (RR 0.5, 95% CI 0.3–0.9) and increased support for a less restrictive policy (RR 3.7, 95% CI 1.4–10.3). It is perhaps important to note that religiousness, not religious background, was associated with support for a more restrictive policy, which is not surprising, given that adherence to religion can vary.

Discussion This study presents the findings of a large, representative sample of obstetricians from NICU-associated maternity

units in eight European countries. The census or random sampling strategy, which was adopted, and the overall high obstetricians’ response rate within the recruited units (77%) support the validity of our data, although in some countries, a lower unit recruitment fraction might have impaired the representativeness of the results at national level. There are considerable legal restrictions on late termination of pregnancy, although these vary from one country to the other (Box). It is worthwhile considering the situation in Sweden, where termination of pregnancy is virtually forbidden after viability; thus, Swedish obstetricians were less likely to encounter late termination and the associated dilemmas. It is interesting to note that they were also the least likely to support less severe restrictions. While the number of responders who encountered late termination provides no indication of its incidence, it demonstrates that this is a real issue facing clinicians, at least in large maternity hospitals. Management of late terminations has important moral and emotional consequences.4 About half the respondents have encountered a situation of a live birth following late termination. This research demonstrated wide variations in practice between countries in a difficult and a sensitive area. Neonatologists were most likely to be alerted in Italy and this may be linked to a higher rate of admission to neonatal units, a practice that may be dictated by legal requirement.17,18 More

Box. Summary of legal position with regards to late termination of pregnancy in participating countries Italy

Termination of pregnancy after 90 days is permitted only: (a) in case of a serious risk for the woman’s life; (b) in case of relevant fetal anomalies that can cause a serious risk for the woman’s physical or mental health. This implies that, in no case, fetal disability may be considered as a direct reason for abortion. When there is a possibility of autonomous fetal life, termination of pregnancy is permitted only in case (a) and the physician must adopt all the measures that can save the life of the fetus. Spain The limit of termination for fetal anomalies (severe physical or mental abnormalities) is 22 weeks. There is no time limit if there is a risk to the mother’s physical or mental health. France Termination of pregnancy may be performed at any stage of gestation if there is a strong possibility that the unborn child is suffering from a serious incurable condition. Germany The new law framed abortion as illegal but not punishable. Late termination of pregnancy is allowed if necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman, but without imposing the three day wait period and the requirement that the woman undergoes directive anti-abortion counselling (as required for women undergoing abortion before 12 weeks). Fetal disability is not stated as a legal reason for abortion. the Netherlands The law allows termination up to 24 weeks amenorrhoea. Termination after 24 weeks is allowed and a possible crime not considered for conditions (category 1), which will lead to early neonatal death. A criminal case may follow termination for conditions (catagory 2), which may lead to survival with irreparable defects. In such cases, doctors seek support from professional bodies. Luxembourg Abortion after 12 weeks can be performed only if two doctors certify in writing that qu’il existe une menace tre`s grave pour la sante´ ou la vie de la femme enceinte ou de l’enfant a` naıˆtrthere is a very serious threat to the health or life of the mother or the unborn child. UK Abortion is legal with no gestation limit if: (a) the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated; or (b) the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or (c) there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped. Sweden After 18 weeks, permission must be obtained from the National Board of Health and Welfare. Abortion is not allowed if the fetus is capable of survival, which is taken to be 22 weeks.

1346



obstetricians in France would consider euthanasia after delivery in case of a live birth despite the French legal position.4 Arguments have been advanced in support of this practice,19,20 which also occurs in the Netherlands.21 Nevertheless, there appears to be a high uptake of feticide using potassium chloride injection as advocated in French literature.22 Feticide is also practiced in Luxembourg and the UK,10 but rarely elsewhere. Feticide may, avoiding legal uncertainties,10,11 reduce psychological harm and may also safeguard the women’s decision for termination as it assures her right for non-interference and eliminates the potential for coercive intervention by other healthcare personnel.23 Intracardiac potassium chloride injection is the method most commonly used for intrauterine feticide, but the practice is rare outside France, Luxembourg and the UK. It is possible that the role of feticide is somewhat limited because doctors (and patients) may not see a major distinction between intra- and extra-uterine death in these circumstances or that practice varies depending on local service availability. It is interesting to note that the administration of potassium chloride to the fetus is legal in countries such as Spain, where it is rarely, if ever, practiced. How to manage a live birth following late termination of pregnancy is a question that warrants careful consideration. Doctors are faced with a difficult dilemma and have to balance their moral and ethical beliefs, the ambiguous legal status and the need to provide sensitive patient care at a difficult time. The practice in some countries like Italy favours neonatal resuscitation and intensive care, which if successful will compound the risks of prematurity with those linked to the original fetal condition. Advocates of active euthanasia as practised in France and which can result in criminal prosecution in countries like the UK, would argue that it is more humane than allowing the premature liveborn to die a slow or protracted death. It is perhaps not surprising that a large proportion of obstetricians hand over this difficult decision to neonatologists. It is perhaps surprising that Down syndrome features highly among the indication for late termination of pregnancy in these countries, given the possibility of earlier detection using biochemical and ultrasound screening and confirmatory genetic testing. Down syndrome accounted for 12 out of the 136 (8.8%) terminations of pregnancy performed after 24 weeks in England and Wales in 2006. Other indications included CNS malformations (60, 44%), hydrocephalus (10, 7.3%) and cardiovascular anomalies (13, 9.5%).24 The many differences between countries are not surprising, because evaluating the significance of identified anomalies and the risk of handicap is subjective. This is supported by Statham et al.25 who found differences among fetal medicine specialists about which anomaly they would consider to justify termination of pregnancy, as well

as in their willingness to become involved in the process.25 A very small minority of participants encountered late termination for social reasons. This remains difficult to explain given that it is not provided for in legislation. In a survey of 391 obstetric consultants in the UK, 64% stated that they would offer termination for anencephaly after 24 weeks, 13% would offer termination for Down syndrome and 21% would offer termination for spina bifida after 24 weeks.7 What constitutes a serious abnormality is difficult to define, not the least because of difficulties inherent in predicting functional states from antenatal images or test results and as the severity of a condition can vary considerably. There are also difficulties in defining those conditions where a pregnancy termination could be undertaken to protect the physical or the mental health of the woman and our research suggests considerable impact of prevalent norms. This can raise the criticism that broadly similar laws are being inconsistently applied. A similar point was made by Savulescu.26 Green, called for clarification of the law, but this may not be easily achieved.2 Our research is in broad agreement with earlier research from the Netherlands, which showed that gynaecologists address this area of practice carefully, but that guidelines remain inconsistently applied.21,27 Only about half the respondents explore the possibility of live birth with women. This may reflect the sensitivity and the difficulties inherent in counselling at a traumatic and stressful time. But not discussing such issues, especially in countries where feticide is not commonly practised, is problematic. Concerns continue to be raised about the quality of information and counselling prior to antenatal screening and related interventions4 and adequate resources need to be directed to addressing this issue. These research findings indicate considerable uncertainty and conflict as exemplified by the relatively high proportion of calls to neonatologists and the limited agreement between what doctors say they do and their preferred action. This is perhaps exacerbated by the fact that feticide or the possibility that the fetus may survive is the issues discussed least frequently with the mother. Nevertheless, it seems that passive euthanasia is preferred to active euthanasia except in France. Assessment and resuscitation at the time of birth are supported by a small number of obstetricians. Despite these uncertainties, except in Italy, the majority of obstetricians supported current practice in their countries. The majority of those who favoured change would prefer more rather than less severe restrictions. The strongest call for more restriction comes from Italy and Germany, while the strongest call for less restriction comes from Spain, the Netherlands and also Italy where medical opinion seems more polarised. These findings were confirmed after adjusting for possible confounders in the


1347

Habiba et al.

multivariable model. Taking France as a reference point, Italy emerged as one of the countries associated with a higher likelihood of support for a less restrictive policy. This creates an apparent contradiction, indicative of divided views, as the majority of obstetricians in Italy remain in favour of either current policy or more restrictions. It is well recognised that late terminations are associated with higher complication rates, require more resources and emotional support for patients and staff. But although most anomalies can be diagnosed and managed early in pregnancy, it is likely that the question of late termination will continue to arise.28 The case for late termination becomes more compelling if the fetal condition is not compatible with life,29 but these are not the only conditions currently considered as justification for late termination. Indications considered for termination of pregnancy include other fetal conditions short of lethal anomalies, as well as maternal indications. The place for maternal choice is also recognised, but highly controversial or indeed illegal in many countries.

Conclusion This research outlines current practice and the many uncertainties encountered in this difficult and sensitive area where there remains a need for support for all those who were involved. Most obstetricians are satisfied with the status quo in their respective countries; those who were dissatisfied were more likely to call for more severe restrictions.

Conflicts of interest None.

Contribution to authorship M.H. wrote the manuscript, M.Da.F. analysed the data, all coauthors contributed to manuscript and to the conduct of the study in their respective countries.

Details of ethics approval Ethics approval was deemed not to be necessary.

Funding The results presented in this study are part of the European Concerted Action project EUROBS on ‘Developments of perinatal technology and ethical decision-making during pregnancy and birth: the obstetricians’ perspective’ funded by the European Commission (Contract n. BMH4CT98-3376, Project coordinator Marina Cuttini, IRCCS Burlo Garofolo, Trieste). The views expressed are those of the Authors and the sponsor has played no part in study design, execution,

1348

analysis, preparing or reviewing the manuscript. The decision to submit for publication is that of the authors and the corresponding author. Dr Marina Cuttini acts as custodian for the data.

Acknowledgements We are very grateful to our colleagues who answered our questionnaire. We also acknowledge other members of the EUROBS study Group: Dr Marina Cuttini (Italy) study lead, M. Garel (France); P. Benciolini and R. Saracci (Italy), Juliań Librero (Spain). T. Nilstun (Sweden), I. de Beaufort (the Netherlands). j

References 1 Lilford RJ, Thornton J. Ethics and late termination of pregnancy. Lancet 1993;342:499. 2 Green JM. Ethics and late termination of pregnancy. Lancet 1993;342:1179. 3 Paintin D. Abortion after 24 weeks. Br J Obstet Gynaecol 1997;104:398–400. 4 Garel M, Gosme-Seguret S, Kaminski M, Cuttini M. Ethical decisionmaking in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives. Prenat Diagn 2002;22:811–7. 5 ONS. [www.statistics.gov.uk/STATBASE/ssdataset.asp?vlnk=9520]. Accessed 6 December 2008. Office of National Statistics 2008. 6 Vadeyar S, Johnston TA, Sidebotham M, Sands J. Neonatal death following termination of pregnancy. BJOG 2005;112:1159–62. 7 Green JM. Obstetricians’ views on prenatal diagnosis and termination of pregnancy: 1980 compared with 1993. Br J Obstet Gynaecol 1995;102:228–32. 8 RCOG. Report of the RCOG Working Party on Termination of Pregnancy for Fetal Abnormality in England, Wales and Scotland. London: RCOG, 1996. 9 RCOG. Report of the RCOG Ethics Committee on a Consideration of the Law and Ethics in Relation to Late Termination of Pregnancy for Fetal Abnormality. London: RCOG, 1998. 10 RCOG. Further issues relating to late abortion, fetal viability and registration of births and deaths. 2001 [www.rcog.org.uk/ womens-health/clinical-guidance/further-issues-relating-late-abortionfetal-viability-and-registrati]. Accessed 28 April 2009. 11 Nuffield Council on Bioethics. Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues. London: Nuffield Council on Bioethics, 2006. 12 Habiba M, Kaminski M, Da Fre M, Marsal K, Bleker O, Librero J, et al. Caesarean section on request: a comparison of obstetricians’ attitudes in eight European countries. BJOG 2006;113:647–56. 13 Cuttini M, Habiba M, Nilstun T, Donfrancesco S, Garel M, Arnaud C, et al. Patient refusal of emergency cesarean delivery: a study of obstetricians’ attitudes in Europe. Obstet Gynecol 2006;108:1121–9. 14 Cuttini M, Kaminski M, Garel M, Lenoir S, Saracci R. End-of-life decisions in neonatal intensive care. Lancet 2000;356:2190–1. 15 Cuttini M, Rebagliato M, Bortoli P, Hansen G, de Leeuw R, Lenoir S, et al. Parental visiting, communication, and participation in ethical decisions: a comparison of neonatal unit policies in Europe. Arch Dis Child Fetal Neonatal Ed 1999;81:F84–91. 16 Lemeshow S, Letenneur L, Dartigues JF, Lafont S, Orgogozo JM, Commenges D. Illustration of analysis taking into account complex survey considerations: the association between wine consumption



17

18

19

20

21

22 23

and dementia in the PAQUID study. Personnes Ages Quid. Am J Epidemiol 1998;148:298–306. Pignotti MS. [The Italian law on termination of pregnancy (194/ 1978). Should it be revised? The palliative care option]. Recenti Prog Med 2007;98:607–10. Pignotti MS. [Birth after late termination of pregnancy: a neonatologist’s point of view]. Recenti Prog Med 2007;98: 479–83. Dehan M. [Limitation of intensive care and infant death during the postnatal period]. J Gynecol Obstet Biol Reprod (Paris) 2002;1 (Suppl):2S94–7. Vial M, Boithias C, Audibert F, Frydman R, Dehan M. [Accompanying babies to death after late termination of pregnancy]. J Gynecol Obstet Biol Reprod (Paris) 2002;1(Suppl):2S98–102. Bosma JM, van der Wal G, Hosman-Benjaminse SL. Late termination of pregnancy in North Holland. Br J Obstet Gynaecol 1997;104: 478–87. Mahieu-Caputo D, Dumez Y. L’arreˆt de vie in utero. Med Foet et Echo Gynecol 1999;40:15. Fletcher JC, Isada NB, Pryde PG, Johnson MP, Evans MI. Fetal intracardiac potassium chloride injection to avoid the hopeless resuscita-

24

25

26

27

28 29

tion of an abnormal abortus: II. Ethical issues. Obstet Gynecol 1992; 80:310–3. Service GS. Abortion statistics, England and Wales. 2006 [www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications Statistics/DH_075697]. Accessed 28 April 2009. DoH Statistical Bulletin. DoH, 2006. Statham H, Solomou W, Green J. Late termination of pregnancy: law, policy and decision making in four English fetal medicine units. BJOG 2006;113:1402–11. Savulescu J. Is current practice around late termination of pregnancy eugenic and discriminatory? Maternal interests and abortion. J Med Ethics 2001;27:165–71. Bosma JM, van der Wal G, Hosman-Benjaminse SL. [Late pregnancy interruption in Noord-Holland. II. Carefulness before and review afterwards]. Ned Tijdschr Geneeskd 1996;140:605–9. Grimes DA. The continuing need for late abortions. JAMA 1998; 280:747–50. Chervenak FA, Farley MA, Walters L, Hobbins JC, Mahoney MJ. When is termination of pregnancy during the third trimester morally justifiable? N Engl J Med 1984;310:501–4.


1349