CORRESPONDENCE

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Abortion rates still rising

SIR, - A recent report from the Office of Population
Censuses and Surveys' has been widely quoted in
the press,2 3and was reported by Ms Luisa Dillner,4
as indicating that the abortion rate has tripled in
the past 20 years in England and Wales. Detailed
analysis of these figures, however, shows that
requests for abortion have remained remarkably
constant since 1972 (figure).
The initial rapid rise from 3-5/1000 women aged
15-44 in 1968 (the first year when abortions were
notified) to a level rate of 11 0/1000 in the 1970s
probably reflects the increasing availability of legal
termination of pregnancy and corresponds to a
decrease in illegal abortion. Much of the modest
increase since then (35%) can be explained by
demographic changes rather than a profound
change in women's requests for abortion. Women
born during the "baby boom" of 1960-5 reached
sexual maturity during the 1980s, and hence a
larger proportion of the female population is at risk
of unwanted pregnancy. The Office of Population
Censuses and Surveys calculated that because
there has been an increase in the proportion of
women aged between 16 and 29 (a group that has a
higher termination rate than older women) without
any change in the age specific termination rates the
number of terminations would have been expected
to increase by 14% between 1972 and 1989.
The remaining increase is likely to be due mainly
to a gradual change in the attitudes of doctors,
and particularly gynaecologists, to therapeutic
abortion in certain parts of the country. In Scotland
there were appreciable regional differences in the
abortion rate in 1972, with the rate in the west
being half that in the north and east. Though the
rates in the east and north have remained fairly
constant over the past 20 years (for example, that
in Grampian), the rate in Greater Glasgow has
doubled to reach the national average. These
differences probably reflect the influence of two

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1970 1974 1976

1980 1984

1988

Abortion rate among women aged 1544 in Grampian

region, Greater Glasgow, Scotland, and England and
Wales, 1970-88
*Figures for North East Scotland Regional Hospital Board. tFigures

for West ofScotland Regional Hospital Board.

BMJ

VOLUME 303

7 SEPTEMBER 1991

eminent senior gynaecologists. My father, Sir

Dugald Baird, who worked in Aberdeen, played an
important part in supporting the change in the
Abortion Law in 1967; Professor Ian Donald in
Glasgow was vehemently opposed to therapeutic
abortion. Though religious and social factors may
have had some role, it seems unlikely that the rise
in abortion rate in Glasgow is totally unrelated to
the retiral of Professor Donald in 1976. Similar
regional differences in attitudes existed throughout
England and Wales, and hence the increase in the
abortion rate nationally probably reflects the
gradual levelling out of provision of abortion
services rather than an increased resort to abortion
as a means of controlling fertility.
A major factor determining the demand for
abortion is the provision of contraceptive services.
The abortion rate in Scotland (9-8/1000 women
in 1989) is lower than that in most European
countries and less than one third that in the United
States' partly because contraception is widely
available to all sections of the community from the
NHS. Recent attempts by many health authorities
to limit the provision of "social" sterilisations and
to reduce budgets for family planning services may
lead to a rise in the incidence of unplanned and
unwanted pregnancies. The consequent increase
in the demand for therapeutic abortion would be
very undesirable at a personal level and would put
increasing strain on medical services.
DAVID T BAIRD

Centre for Reproductive Biology,

Department ot Obstetrics and Gynaccology,
University of Edinburgh,
Edinburgh EH3 9EW
I Office of lopulation Censuses and Surveys. 'I'rends in abortion.
In: Population trends 64. London: Government Statistical
Service, 1991:19-29.
2 Fletcher D. Abortion rate has trebled in 20 years. Daily Telegraph
1991 June 19:4(col 1).
3 Hunit L. Abortions on the increase. Independent 1991 June
19:4(col ).
4 Dillner L. Abortion rates still rising. BMJ 1991;302:1559-60.
(29 June.)
5 Henshaw SK. Induced abortion: a world review. Family
Planning Perspecti'ves 1990;22:76-89.

Vital statistics of births

SIR,-The measurement of maternal mortality
is important enough that a minor point in Dr
Geoffrey Chamberlain's excellent paper' deserves
mention. The denominator for maternal mortality
in a given year is either the total number of births
or the number of live births during that year, not
the number of maternities-the term maternities is
ambiguous. The World Health Organisation's
definition states that "A 'maternal death' is defined
as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective
of the duration and the site of the pregnancy,

from any cause related to or aggravated by the

pregnancy or its management, but not from
accidental or incidental causes" and goes on to
say that "the denominator used for calculating
maternal mortality should be specified as either
the number of live births or the total number of
births (live births plus fetal deaths). Where both
denominators are available, a calculation should be
published for each."2
To allow for an extension of the period during
which deaths can be related to pregnancy or its
outcome, the 1989 international conference for the
tenth revision of the International Classification of
Diseases introduced the concept of late maternal
death: "A 'late maternal death' is defined as the
death of a woman from direct or indirect obstetric
causes more than 42 days but less than one year
after the termination of pregnancy."2
Similarly, the conference has introduced the
concept of "pregnancy related death" to permit
classification of deaths of women while pregnant
or when recently delivered, even though local
facilities may not allow the cause of death to be
identified as "related to or aggravated by the
pregnancy or its management." A pregnancy
related death is thus defined as "the death of a
woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the cause
of death." It. is likely, for instance, that some
homicides and suicides of pregnant or recently
pregnant women fall into this category, and
accidents may also be considered in this light,
in so far as fatigue or reduced mobility in advanced
pregnancy affects ability to avoid or survive
accidents.'
A C P' L'HOURS
M C THURIAUX

Division ot Epidemiological Surveillance and

Health Situation and Trend Assessment
Strengthening of Epidemiological and
Statistical Services,
World Health Organisation,

1211 Geneva,
Switzcrland
I Chamberlain G. Vital statistics of births. BMJ 1991;303:178-8 1.
(20 July.)
2 International conference for the tenth revision of the International
Classification of I)iseases, Geneva, 26 September-2 October
1989. Wttrld Health Statistics Quarterly 1990;43:204-45.
3 Fortney JA. Implications of the ICD-I( definitions related to
death in pregnancy, childbirth or the puerpwrium. World
Health Statistics Quarterly 1990;43:246-8.

Nursing: an intellectual activity

SIR,-For doctors to comment on matters concerning nursing risks touching a raw nerve-the
"doctor's handmaiden" nerve-but the forthright
views of June Clark, a professor of nursing,
deserve discussion.' Doctors and nurses need each
579

other. They learn from each other. And if they

don't work well together it's the patient who
suffers. Both professions ought to be mature
enough to discuss the problems of the other from
time to time without coming to blows over it.
Our goals are surely the same. Those listed by
Professor Clark are the goals of all health workers,
not just of nurses. Certainly you can't be a good
doctor if you don't consider the whole patient, as
leaders of the medical profession like Lister and
Osler emphasised 100 years ago.
Secondly, I fear that many doctors will not be
happy with either of the suggested "two ways of
looking at nursing." Those who are said to look at
nursing in the first way (which is described as
the more prevalent of the two perspectives) are
accused of believing that nurses do not require an
understanding of why a task is necessary, how it
works, or what its effects will be. But surely
nobody thinks this. Anyone with a grain of sense
wants each member of a team to have as much
understanding as possible of what is being done for
a patient. Why else should nurses have lectures
from specialists explaining the thinking behind
different surgical and medical treatments?
As regards Professor Clark's second way of
looking at nursing, everyone will agree with much
of what she says and with the progress towards an
even better trained, understanding, and skilful
nursing profession. But it seems to me that to
achieve what she would apparently like to see for
all nurses (examining and history taking, thought
processes identical with those used in medicine,
sophisticated cognitive and social skills, and so on)
would mean that every nurse would have to go
through a course of training very similar to that at
medical schools.
We have all known nurses who, had they chosen
to do so, could have sailed through medical school
with flying colours. But there are many othersequally excellent and with equally good skill and
judgment in many circumstances-who would be
the first to agree that they could never compete or
cope at this intellectual level and wouldn't want to.
It doesn't help patients or anyone else to pretend
otherwise. To be blunt, what is at stake here, it
seems to me, is the credibility of those leaders of
the nursing profession who brush reality under the
carpet and talk as if all nurses were broadly the
same in this respect.
THURSTAN B BREWIN
Bray,
Berkshire SL6 2BQ
1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7.
(17 August.)

SIR,-IS Professor June Clark suggesting that,

though the thought processes in nursing are
identical with those in medicine, nursing alone
focuses on the "human response" and the "uniqueness of the individual"?'
Perhaps she has a vision of care provided by
a multidisciplinary team led by nurses, with
psychologists providing counselling or behavioural
management for problems that the nurse does
not have time for and doctors available to sign
prescriptions and undertake manual tasks such as
pinning femurs and performing tracheostomies.
When I become helpless, whether from illness,
advancing years, or sheer rage, I hope that there will
be someone in this multidisciplinary team to soothe
my fevered brow and, more importantly, to keep me
clean and dry, thus avoiding the bedsores that seem
so common.
S BRANDON

University of Leicester School of Medicine,

Leicester Royal Infirmary,
PO Box 65,
Leicester LE2 7LX
1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7.
(17 August.)

580

SIR,-Professor June Clarke's editorial on nursing

interested me as I am a qualified nurse as well as a
qualified doctor. When I decided on a career in
nursing I had only two 0 levels. Fortunately, I
passed the entrance exam and spent eight happy
years as a nurse. My training was intense and
stimulating and had a strong element of discipline.
I changed my profession not because I didn't enjoy
nursing but because I was searching for a different
sort of challenge.
I am saddened by the standards of nursing care
today. Nurses no longer have time to sit and
provide that all important emotional support.
They say that they are understaffed, but perhaps
they are too busy writing care plans and evaluating
the care that they have been too busy to provide.
I agree that nursing requires a good intellect, but
raising the entry requirement means that some real
nurses are excluded. After all, had I applied 10
years later to become a nurse I would not have been
accepted with my two meagre 0 levels. I believe
that standards are falling partly because of this
leaning towards academia. It is difficult to see how
a degree in nursing produces better nurses when
they spend more time in a classroom than at
the bedside. Of course good clinical research is
needed, but not at the expense of good nurses
on the wards, where practical skills are vital.
If nurses want to be "clinical specialists" why
don't they change professions like I did? Believe
me, the grass is not greener on the other side.
SALLY-ANN HAYWARD

London NW6 3HP

I Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7.
(17 Augist.)

SIR,-As I read Professor June Clark's editorial on

recognising nursing's intellectual component' I
thought of the women who, on several occasions,
have promoted my "physical and mental comfort,
healing, and recovery" and wondered what they
would have made of it. They would probably have
asked, "What on earth is she on about?"
Years ago I watched a district nurse restore my
badly burnt 80 year old grandfather through
convalescence to renewed self confidence. A
"considerable intellectual and emotional challenge"? She would have been mystified. She was
simply doing her job and doing it superbly; and she
was not exceptional.
The intellectual component has always been
present, and recognised. But we didn't call it that.
We called it basic intelligence and common sense.
To talk now of "coherent and holistic care" and
"extant definitions of quality care" is to use the
worst kind of academic jargon. Sadly, this is not an
isolated example-the whole article reeks of it.
I feel a sense of outrage on behalf of the women
who nursed me, some of whom became valued
friends of the family. If I was a young woman
considering nursing today I would be frightened off
by this article. I am afraid that many will be.
KATHLEEN NORCROSS
Birmingham B29 7JA
1 Clark J. Nursing: an intellectual activity. BMJ 1991;303:376-7.
(17 August.)

HIV transmission during

surgery
SIR,-We should like to clarify certain issues
raised by Dr A G Bird and colleagues.' These
remarks concern the case of the HIV infected
gynaecologist who agreed that the 1000 patients he
had operated on should be contacted.

Letters were sent to patients in the three districts.

They were offered initial counselling by telephone
helpline and then encouraged to attend for further
counselling and discussion at convenient centres.
Alternative arrangements for counselling were also
catered for, including home visits for those unable
to take time off work or with transport difficulties,
and an option of attending their own general
practitioner instead of the organised counselling
sessions. The general practitioners had been
advised separately about the nature of the incident.
No patients were discouraged from having a
test, and the genitourinary clinics were used only
for counselling and testing within one district,
where other facilities were not readily available.
That many patients chose to have a test after
counselling was in part related to their level of
anxiety on receipt of the letter. The role of the
counsellors was to offer impartial information and
not to persuade or dissuade patients from having a
test.
The Association of British Insurers, by recommending a waiver note for patients taking the test,
may have only confused its prevailing message. In
April 1991 a "statement of practice" was produced
by the association, reiterating that a negative HIV
test in the absence of lifestyle risk factors would not
jeopardise insurance premiums on any occasion. A
waiver notice was therefore not strictly necessary,
but the machinery to produce this had in any case
been put into operation well before the events
became public.
Whereas it may be claimed that the exercise
illustrated could have been used to provide even
greater epidemiological information, there is no
evidence from the evaluation of work carried out
locally in the health authorities of any "collective
denial" hindering epidemiological assessment.
Indeed, our objectives included acknowledgment
of the potential risk (however small), sympathetic
and confidential management of the individuals
concerned, and delivery of unbiased and correct
information to the public.
The success of the exercise cannot be judged by
the level of HIV testing achieved, but rather by the
dissipation of anxiety and uncertainty of all those
involved.
S C CRAWSHAW
R J WEST

West Suffolk Health Authority,

Bury St Edmunds,
Suffolk IP33 I YJ
1 Bird AG, Gore SM, Leigh-Brown AJ, Carter DC. Escape from
collective denial: HIV transniission during surgery. BMJ
1991;303:351-2. (10 August.)

Guidelines for doctors with HIV

infection
SIR, -In DrMichaelMorris'seditorialonAmerican
legislation on AIDS' the tired old guidelines from
the General Medical Council are repeated yet
again: "It is unethical for physicians who know or
believe themselves to be infected with HIV to
put patients at risk by failing to seek appropriate
counselling or act upon it when given."
This will not do. AIDS may eventually kill the
unfortunate surgeon who is HIV positive, but if
he abandons his livelihood poverty, loneliness,
depression, and debt will kill him sooner. His
family surely have enough to cope with without
losing their house and facing a mountain of debt.
If those eminent people who formulate such
guidelines truly believe them then we must pay
those whose counselling leads them to give up their
profession the full rate for the job they are leaving.
When the Ministry of Agriculture, Fisheries, and
Food destroys livestock to control an outbreak of
foot and mouth disease it pays the full market rate
for the animals it destroys, otherwise the farmers
would not always cooperate. If we really want to

BMJ VOLUME 303

7 SEPTEMBER 1991