SEARCH

SEARCH BY CITATION

Keywords:

  • Late abortion;
  • termination of pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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

Design  Cluster sampling cross-sectional survey. All neonatal 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.

Main outcome measure  Obstetricians’ experience of late termination of pregnancy and views about national policies.

Results  One hundred and five units and 1530 obstetricians 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.

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.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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. 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 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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, non-responders 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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 socio-demographic 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, 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.

Table 1.   Socio-demographic and professional characteristics of responding obstetricians (unweighted proportions), n (%)
 ItalySpainFranceGermanythe NetherlandsLuxembourgUKSweden
Number of responders (response rate)383 (90)328 (80)100 (93)139 (63)126 (74)15 (79)163 (65)276 (74)
Gender
Male241 (64)169 (52)63 (63)71 (51)64 (51)10 (67)84 (52)127 (46)
Female133 (36)155 (48)37 (37)68 (49)61 (49)5 (33)76 (47)147 (54)
Age (years)
Under 3035 (9)68 (21)17 (17)24 (17)10 (8)2 (13)18 (11)3 (1)
30–3967 (18)103 (32)46 (46)73 (53)65 (52)5 (33)85 (53)60 (22)
40–49124 (33)78 (24)22 (22)23 (17)27 (22)6 (40)45 (28)102 (37)
50 and over149 (40)75 (23)15 (15)19 (14)23 (18)2 (13)12 (7)109 (40)
Having had children
Yes264 (70)195 (60)71 (71)58 (42)80 (64)9 (60)102 (64)249 (91)
No111 (30)128 (40)29 (29)81 (58)45 (36)6 (40)58 (36)25 (9)
Religious background
None7 (2)8 (2)15 (15)20 (14)35 (28)2 (13)18 (11)40 (15)
Roman catholic365 (97)311 (96)70 (70)58 (42)49 (39)12 (80)27 (17)7 (3)
Protestant1 (0.3)1 (0.3)3 (3)59 (42)37 (30)1 (7)60 (38)222 (81)
Other2 (0.5)4 (1)12 (12)2 (1)4 (3)054 (34)5 (2)
Importance of religion in one’s life
Extremely important64 (17)33 (10)6 (6)7 (5)5 (4)034 (22)24 (9)
Fairly important174 (47)119 (37)25 (25)64 (48)15 (12)3 (20)58 (37)41 (16)
Not very important81 (22)128 (40)38 (38)39 (30)62 (50)8 (53)25 (16)97 (37)
Not at all important51 (14)42 (13)31 (31)22 (17)43 (34)4 (27)38 (25)101 (38)
Professional position
Unit head/adjunct head87 (23)43 (13)18 (18)25 (18)10 (8)1 (7)10 (6)26 (9)
Specialist226 (60)199 (61)58 (59)47 (35)59 (47)10 (71)65 (40)212 (77)
Trainee64 (17)86 (26)23 (23)64 (47)56 (45)3 (21)87 (54)37 (13)
Hospital appointment
Full-time329 (86)288 (88)97 (97)130 (94)109 (87)6 (40)149 (92)246 (89)
Part-time52 (14)40 (12)3 (3)8 (6)17 (13)9 (60)13 (8)29 (11)
>2 years of routine antenatal ultrasound practice
Yes169 (44)113 (35)47 (47)73 (53)63 (50)9 (64)68 (42)128 (47)
No214 (56)214 (65)53 (53)66 (47)62 (50)5 (36)95 (58)147 (53)

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%), Luxembourg (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.

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)
  1. *Items ‘Induced’ and ‘Assisted’ are not mutually exclusive.

  2. **Proportions computed among responders having induced or assisted late therapeutic abortions in the preceding three years.

 ItalySpainFranceGermanythe NetherlandsLuxembourgUKSweden
In the last three years, have you ever induced OR assisted ‘late’ therapeutic abortions (after 23 completed weeks)?*
Induced13 (8–20)17 (12–25)66 (53–77)39 (27–52)44 (32–57)67 (47–82)58 (49–67) 9 (5–15)
Assisted52 (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  assisted40 (31–50)69 (58–78) 7 (4–13)41 (26–58)44 (30–60)13 (8–22)35 (27–44)84 (77–89)
Which were indication(s) for the abortion(s) after 23 completed weeks? (more than one answer possible)**
Fetal congenital malformation(s)89 (85–93)79 (65–88)96 (89–98)77 (58–89)94 (84–98)92 (86–96)99 (93–99)86 (77–92)
Down syndrome67 (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 disorders54 (45–63)44 (34–55)89 (78–95)68 (52–80)62 (54–70)77 (60–88)69 (61–75)63 (48–75)
Prenatal infection22 (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 physical health24 (16–35)37 (23–52)51 (36–66)34 (20–51)52 (39–65) 8 (4–14)47 (36–58)28 (17–43)
To protect the woman’s mental health49 (37–61) 9 (4–18)27 (12–50)19 (15–25) 6 (3–12) 010 (7–15)12 (2–44)
Social reasons12 (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 hypertonic solution 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)
Administration of KCl to the fetus 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)
Mechanical compression of the  umbilical cord 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)
Other 0   7 (2–23) 2 (0.6–8) 2 (0.3–7) 5 (1–15) 0 8 (4–16) 0

The fetus

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 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.

Table 3.   Live born foetus following late therapeutic abortion (weighted proportion and 95% confidence intervals)
  1. *Proportions computed among responders having induced or assisted late therapeutic abortions in the preceding three years.

  2. **Proportions computed among responders having encountered the situation of a live born foetus following induced late therapeutic abortion.

 ItalySpainFranceGermanythe NetherlandsLuxembourgUKSweden
Have you ever encountered the situation of a live born foetus following induced late therapeutic abortion?*
Yes54 (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 only10 (6–16)45 (28–63) 4 (1–14)62 (47–75)74 (66–81)5058 (43–72)35 (27–44)
Neonatologist was alerted and made decision93 (87–96)45 (33–58)18 (8–36)78 (42–95)49 (33–65) 056 (31–78)65 (28–90)
Administration of drugs to end life 0 080 (72–87) 0.9 (0.1–7)26 (18–35)25 0 0
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 admission to NICU for life saving treatment35 (24–47) 9 (4–20) 0 8 (3–21) 0 0 3 (0.6–13)14 (6–27)
No resuscitation and nursing care only39 (30–48)43 (35–51) 9 (5–16)64 (44–80)34 (25–45)31 (20–44)71 (59–81)48 (35–61)
Administration of drug to end life 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)
Depends on the baby’s condition10 (7–16)19 (15–23)14 (9–23)17 (8–31)19 (11–29)15 (8–27)12 (6–21)16 (8–28)
Don’t know10 (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)

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).

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
 ItalySpainFranceGermanythe NetherlandsLuxembourgUKSweden
The method which will be used82 (75–87)86 (76–92)98 (92–99)95 (89–98)10010098 (94–99)95 (83–99)
Type of maternal anaesthesia/analgesia59 (51–67)81 (70–88)96 (90–98)90 (81–95)10010097 (93–99)93 (78–98)
Duration of the procedure63 (54–71)72 (63–80)85 (73–92)95 (81–99) 99 (88–99.8) 92 (24–99.8)93 (89–96)88 (79–94)
Possible unwanted adverse effects57 (48–65)71 (62–79)52 (42–61)87 (71–95) 88 (79–94) 69 (56–80)91 (82–96)84 (77–89)
Possibility that the fetus may survive the abortion procedure43 (34–52)19 (13–27)14 (7–25)79 (65–88) 83 (70–90) 15 (8–27)57 (40–73)37 (15–66)
Possibility of feticide 8 (5–12) 8 (5–14)70 (55–82)31 (18–49) 20 (13–30) 38 (19–63)81 (74–86) 7 (3–15)
Possibility of seeing the fetus after the abortion17 (12–23)29 (17–45)94 (88–97)91 (83–96) 99 (90–99.8) 92 (24–99.8)90 (81–96)79 (57–92)
When medically indicated, authorisation for post-mortem examination59 (48–69)88 (77–94)96 (92–98)90 (79–96) 96 (87–99)10096 (88–99)86 (71–94)
Disposal of the body and/or funeral arrangements29 (19–41)53 (42–64)69 (56–79)87 (73–94) 91 (83–96) 85 (73–92)71 (53–85)84 (71–91)
Possibility of psychological support for the woman53 (44–62)57 (47–66)97 (88–99)70 (58–80) 90 (79–95)10082 (71–89)95 (85–99)
Other 0.9 (0.2–4) 2 (0.6–9) 5 (2–15) 0  9 (4–16)  0 5 (2–11) 0

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.

image

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.

Download figure to PowerPoint

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 a change from current policy compared to obstetricians in France.

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 changeAbortions after 23 weeks should be less severely restricted than they currently are vs. no changeP value**
RR* (95% CI)RR* (95% CI)
  1. *Risk ratio were adjusted for all the variables listed herein.

  2. **P values refer to the overall statistical significance of the association between the explanatory variable and the outcome.

Country<0.001
France1.01.0 
Germany3.7 (1.4–9.6)1.0 (0.3–3.7) 
Italy6.5 (2.6–16.6)4.3 (1.4–13.1) 
Luxembourg0.5 (0.2–1.5)1.2 (0.3–4.6) 
the Netherlands0.7 (0.2–2.0)3.7 (1.1–12.5) 
Spain1.7 (0.6–4.4)10.1 (3.6–28.5) 
Sweden1.4 (0.6–3.4)0.6 (0.2–1.9) 
UK1.5 (0.6–3.6)1.1 (0.3–4.0) 
GenderNo childrenHaving childrenNo childrenHaving children 
Male1.01.01.01.0 
Female0.6 (0.4–1.1)1.5 (1.1–2.2)0.5 (0.1–1.9)0.8 (0.5–1.3) 
Age0.036
<40 years1.01.0 
≥40 years1.2 (0.7–2.0)0.6 (0.4–0.96) 
Importance of religion0.040
Extremely important1.01.0 
Fairly important0.9 (0.5–1.9)2.3 (0.9–6.2) 
Not very important0.8 (0.5–1.4)2.3 (0.9–5.8) 
Not at all important0.5 (0.3–0.9)3.7 (1.4–10.3) 
Having performed antenatal ultrasound examinations routinely for >2 years0.009
No1.01.0 
Yes1.0 (0.8–1.4)1.9 (1.3–3.0) 

Differences between countries remained statistically significant after potential confounders were controlled for. In Germany, obstetricians were more likely to support a more restrictive policy, while in Spain and the Netherlands, obstetricians were more probably to feel that policy should be less restrictive. In Italy, the opinion was more polarised with support for a more and a less restrictive policy (Table 5).

A statistically significant interaction (= 0.020) was found between the obstetricians’ gender and whether they had children; therefore, the risk ratios were reported for both factors. Being a female doctor with children was associated with a higher likelihood of supporting a more restrictive policy (RR 1.5, 95% CI 1.1–2.2); age ≥40 was also associated with reduced support for less restriction. In contrast, routine practice of prenatal ultrasound for >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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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.

Table Box..   Summary of legal position with regards to late termination of pregnancy in participating countries
ItalyTermination 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.
SpainThe 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.
FranceTermination 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.
GermanyThe 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 NetherlandsThe 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.
LuxembourgAbortion after 12 weeks can be performed only if two doctors certify in writing that qu’il existe une menace très grave pour la santé ou la vie de la femme enceinte ou de l’enfant à naîtrthere is a very serious threat to the health or life of the mother or the unborn child.
UKAbortion 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.
SwedenAfter 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.

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 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 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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. BMH4-CT98-3376, 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, 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

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

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), Julián Librero (Spain). T. Nilstun (Sweden), I. de Beaufort (the Netherlands).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Conflicts of interest
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References