'The tabloid test': a qualitative interview study on the function and purpose of termination of pregnancy review committees in Victoria, Australia.

BACKGROUND: Termination of pregnancy (TOP) is not an uncommon procedure. Availability varies greatly between jurisdictions; however, additional institutional processes beyond legislation can also impact care and service delivery. This study serves to examine the role institutional processes can play in the delivery of TOP services, in a jurisdiction where TOP is lawful at all gestations (Victoria, Australia). As per the Abortion Law Reform Act 2008, TOPs post-24 weeks require the approval of two medical practitioners. However, in Victoria, hospitals that offer post-24 week TOPs generally require these cases to additionally go before a termination review committee for assessment prior to the service being provided. These committees are not stipulated in legislation. Information about these committees and how they operate is scarce and there is minimal information available to the public. METHODS: To trace the history, function, and decision-making processes of these committees, we conducted a qualitative interview study. We interviewed 27 healthcare professionals involved with these committees. We used purposive sampling to gain perspectives from a range of professions across 10 hospitals. Interviews were transcribed verbatim, identifying details removed and inductive thematic analysis was performed. RESULTS: Here, we report the three main functions of the committees as described by participants. The functions were to protect: (1) outward appearances; (2) inward functionality; and/or, (3) service users. Function (1) could mean protecting the hospital's reputation, with the "Herald Sun test"-whether the TOP would be acceptable to readers of the Herald Sun, a tabloid newspaper-used as a heuristic. Function (2) related to logistics within the hospital and protecting the psychological wellbeing and personal reputation of healthcare professionals. The final function (3) related to ensuring patients received a high standard of care. CONCLUSIONS: The primary functions of these committees appear to be about protecting hospitals and clinicians within a context where these procedures are controversial and stigmatized. The results of this study provide further clarity on the processes involved in the provision of TOPs at later gestations from the perspectives of the healthcare professionals involved. Institutional processes beyond those required by legislation are put in place by hospitals. These findings highlight the additional challenges faced by patients and their providers when seeking TOP at later gestations.

Abortion can be difficult to access. In Victoria, Australia, under the law, abortion is allowed at any time during a pregnancy­although after you have been pregnant for more than 24 weeks, the approval of two doctors is required. However, hospitals in Victoria that offer late abortions require more than the approval of two doctors. Hospitals have put in place committees that review each case and make a decision about whether the hospital will provide the abortion. There is not a lot of information about these committees­we do not know exactly why they exist, what they are for, or how they work. To find out, we interviewed doctors and other healthcare professionals (like midwives) who were involved in these committees. In this paper, we report the reasons these people gave for why the committees exist and what they are for. There were three main reasons. The first purpose of the committee is so the hospital does not get criticised in newspapers or by other people outside the hospital for performing these late abortions. The second reason is to help and protect those inside the hospital. For example, having a committee means that the doctors do not have to make the decisions themselves. People also said that the committees think about how the staff are feeling. The third reason is so that the hospitals provide the best care they can, and that they can continue to provide late abortions in the future. With this study, we found out some more important information about these committees that we did not have before. What we found shows that it is not just the law that matters­other things can also affect whether you can get an abortion.

Protecting Future Children from In-Utero Harm.

The actions of pregnant women can cause harm to their future children. However, even if the possible harm is serious and likely to occur, the law will generally not intervene. A pregnant woman is an autonomous person who is entitled to make her own decisions. A fetus in-utero has no legal right to protection. In striking contrast, the child, if born alive, may sue for injury in-utero; and the child is entitled to be protected by being removed from her parents if necessary for her protection. Indeed, there is a legal obligation for health professionals to report suspected harm, and for authorities to protect the child's wellbeing. We ask whether such contradictory responses are justified. Should the law intervene where a pregnant woman's actions risk serious and preventable fetal injury? The argument for legal intervention to protect a fetus is sometimes linked to the concept of 'fetal personhood' and the moral status of the fetus. In this article we will suggest that even if the fetus is not regarded as a separate person, and does not have the legal or moral status of a child, indeed, even if the fetus is regarded as having no legal or moral status, there is an ethical and legal case for intervening to prevent serious harm to a future child. We examine the arguments for and against intervention on behalf of the future child, drawing on the example of excessive maternal alcohol intake.

Ethical language and decision-making for prenatally diagnosed lethal malformations.

In clinical practice, and in the medical literature, severe congenital malformations such as trisomy 18, anencephaly, and renal agenesis are frequently referred to as 'lethal' or as 'incompatible with life'. However, there is no agreement about a definition of lethal malformations, nor which conditions should be included in this category. Review of outcomes for malformations commonly designated 'lethal' reveals that prolonged survival is possible, even if rare. This article analyses the concept of lethal malformations and compares it to the problematic concept of 'futility'. We recommend avoiding the term 'lethal' and suggest that counseling should focus on salient prognostic features instead. For conditions with a high chance of early death or profound impairment in survivors despite treatment, perinatal and neonatal palliative care would be ethical. However, active obstetric and neonatal management, if desired, may also sometimes be appropriate.

Homebirth and the future child.

Debate around homebirth typically focuses on the risk of maternal and perinatal mortality and morbidity--the primary focus is on deaths. There is little discussion on the risk of long-term disability to the future child. We argue that maternal and perinatal mortality are truly tragic outcomes, but focusing disproportionately on them overshadows the importance of harm to a future child created by avoidable, foreseeable disability. The interests of future children are of great moral importance. Both professionals and pregnant women have an ethical obligation to minimize risk of long-term harm to the future child; harm to people who will exist is a clear and uncontroversial morally relevant harm. The medical literature does not currently adequately address the risk of long-term disability, which is at least as relevant as other outcomes. The choice of place of elective birth (home, hospital or other) may only be justified if it does not expose the future child to an unreasonable increased risk of avoidable disability. Doctors' duty of care for the life of the pregnant woman and her fetus may be overridden by the woman's choices. But further research is required to document the prevalence of long term avoidable disability associated with different birth place choices. Couples should be informed of this risk and doctors should attempt to dissuade couples when they elect a place of birth that puts the health and well-being of the future child at risk.

Australian attitudes to early and late abortion.

OBJECTIVE: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations. DESIGN, SETTING AND PARTICIPANTS: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008. MAIN OUTCOME MEASURES: Attitudes to abortion, particularly after 24 weeks' gestation. RESULTS: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks' gestation. CONCLUSIONS: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks' gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Pregnant women with fetal abnormalities: the forgotten people in the abortion debate.

Abortion law reform focuses on early abortion. Women wanting to have a family who have a fetal abnormality detected later in pregnancy are neglected in the debate and harmed by the consequences of current legal uncertainty. Unclear abortion laws compromise: the quality of prenatal testing; management when an abnormality is found; and patient care, through obstetricians' fears of legal repercussions. Women carrying a fetus with an abnormality are being denied abortion, even when the abnormality is so severe that non-treatment would be an option if the baby were born. Many women are likely to refuse to consider motherhood if they are denied appropriate prenatal testing and access to abortion if serious abnormalities are detected. Current abortion laws result in discriminatory and inconsistent practices, where access to prenatal testing and termination of pregnancy depends on location, the values of the treating doctor or hospital ethics committee, and a woman's personal resources. Legal certainty is needed to reduce the suffering of couples wanting to have a family.

Abortion: time to clarify Australia's confusing laws.

Australian criminal law is a matter for states and territories. In relation to abortion, many laws are unclear and outdated, and are inconsistent between states and territories. Doctors practise under time constraints and on a case-by-case basis. Most current laws have grey areas that leave doctors vulnerable to accusations, negative publicity and career damage, especially in the case of late abortions. All jurisdictions should follow the Australian Capital Territory's lead in allowing women to access abortion without fear of criminal prosecution. Federal, state and territory governments should introduce a single clear national law on abortion, both in early and late pregnancy.

An ethical approach to giving couples information about their fetus.

The amount of information available to couples about the health of their fetus is increasing. An important question in prenatal diagnosis is what information should be given to couples, and how best to present it. It has been argued elsewhere that, in the absence of economic constraints on testing, there is no place for limiting the information available to couples about their fetus. However, not every couple wants all available information, and it is not always clear what couples do want to know. Providing unwanted information about the health of a fetus may be harmful in a number of ways. Herein, the potential harms of being given unwanted information about one's fetus are illustrated by using case studies drawn from clinical practice, and a new approach to prenatal diagnosis is suggested. If the harms of being given unwanted information about one's fetus are to be avoided, then couples need an opportunity to limit the data gathered about their fetus at prenatal diagnosis.

Words matter: nomenclature and communication in perinatal medicine.

The best interests of our patients are served by using language that both supports patient autonomy and is neutral. While it remains a "tentative" pregnancy (ie, before the completion of normal prenatal tests), the term "fetus" should be used. After normal prenatal testing, only in rare situations will the pregnant woman request an abortion. In such cases, it is appropriate that the term "fetal patient" or the lay terms "child" or "baby" be used. To be a "mother," however, one must have borne a child. Our language should support the autonomous views of the pregnant woman. The language proposed is not intended to be rigidly adhered to in all situations but rather is an appropriate starting point after which one needs to be responsive to the position of the pregnant woman. It is important to individualize language to cater to the views of individual patients. It is, however, time for doctors to acknowledge that their language can influence reality, particularly because they are frequently considered experts not only in prenatal diagnosis but also in morality. Doctor's language has a powerful influence over the way patients think.