Pregnancy

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Abortion rates still risingSIR,-A recent report from the Office ofPopulationCensuses and Surveys' has been widely quoted inthe press,2 3and was reported by Ms Luisa Dillner,4as indicating that the abortion rate has tripled inthe past 20 years in England and Wales. Detailedanalysis of these figures, however, shows thatrequests for abortion have remained remarkablyconstant since 1972 (figure).The initial rapid rise from 3-5/1000 women aged

15-44 in 1968 (the first year when abortions werenotified) to a level rate of 11 0/1000 in the 1970sprobably reflects the increasing availability of legaltermination of pregnancy and corresponds to adecrease in illegal abortion. Much of the modestincrease since then (35%) can be explained bydemographic changes rather than a profoundchange in women's requests for abortion. Womenborn during the "baby boom" of 1960-5 reachedsexual maturity during the 1980s, and hence alarger proportion of the female population is at riskof unwanted pregnancy. The Office of PopulationCensuses and Surveys calculated that becausethere has been an increase in the proportion ofwomen aged between 16 and 29 (a group that has ahigher termination rate than older women) withoutany change in the age specific termination rates thenumber of terminations would have been expectedto 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 therapeuticabortion in certain parts of the country. In Scotlandthere were appreciable regional differences in theabortion rate in 1972, with the rate in the westbeing half that in the north and east. Though therates in the east and north have remained fairlyconstant over the past 20 years (for example, thatin Grampian), the rate in Greater Glasgow hasdoubled to reach the national average. Thesedifferences probably reflect the influence of two

X1 16 pEngland and14 / Wales(o)12 A ,c~~~~ c

E >rGlasgow (e)10 Grampiana(*)88d;/;96 so -'> W < Scotand (o)

S6 *i

Z 21970 1974 1976 1980 1984 1988

Abortion rate among women aged 1544 in Grampianregion, Greater Glasgow, Scotland, and England andWales, 1970-88*Figures for North East Scotland Regional Hospital Board. tFiguresfor West ofScotland Regional Hospital Board.

eminent senior gynaecologists. My father, SirDugald Baird, who worked in Aberdeen, played animportant part in supporting the change in theAbortion Law in 1967; Professor Ian Donald inGlasgow was vehemently opposed to therapeuticabortion. Though religious and social factors mayhave had some role, it seems unlikely that the risein abortion rate in Glasgow is totally unrelated tothe retiral of Professor Donald in 1976. Similarregional differences in attitudes existed throughoutEngland and Wales, and hence the increase in theabortion rate nationally probably reflects thegradual levelling out of provision of abortionservices rather than an increased resort to abortionas 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 womenin 1989) is lower than that in most Europeancountries and less than one third that in the UnitedStates' partly because contraception is widelyavailable to all sections of the community from theNHS. Recent attempts by many health authoritiesto limit the provision of "social" sterilisations andto reduce budgets for family planning services maylead to a rise in the incidence of unplanned andunwanted pregnancies. The consequent increasein the demand for therapeutic abortion would bevery undesirable at a personal level and would putincreasing strain on medical services.

DAVID T BAIRDCentre 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 StatisticalService, 1991:19-29.

2 Fletcher D. Abortion rate has trebled in 20 years. Daily Telegraph1991 June 19:4(col 1).

3 Hunit L. Abortions on the increase. Independent 1991 June19:4(col ).

4 Dillner L. Abortion rates still rising. BMJ 1991;302:1559-60.(29 June.)

5 Henshaw SK. Induced abortion: a world review. FamilyPlanning Perspecti'ves 1990;22:76-89.

Vital statistics of birthsSIR,-The measurement of maternal mortalityis important enough that a minor point in DrGeoffrey Chamberlain's excellent paper' deservesmention. The denominator for maternal mortalityin a given year is either the total number of birthsor the number of live births during that year, notthe number of maternities-the term maternities isambiguous. The World Health Organisation'sdefinition states that "A 'maternal death' is definedas the death of a woman while pregnant or within42 days of termination of pregnancy, irrespectiveof the duration and the site of the pregnancy,

from any cause related to or aggravated by thepregnancy or its management, but not fromaccidental or incidental causes" and goes on tosay that "the denominator used for calculatingmaternal mortality should be specified as eitherthe number of live births or the total number ofbirths (live births plus fetal deaths). Where bothdenominators are available, a calculation should bepublished for each."2To allow for an extension of the period during

which deaths can be related to pregnancy or itsoutcome, the 1989 international conference for thetenth revision of the International Classification ofDiseases introduced the concept of late maternaldeath: "A 'late maternal death' is defined as thedeath of a woman from direct or indirect obstetriccauses more than 42 days but less than one yearafter the termination of pregnancy."2

Similarly, the conference has introduced theconcept of "pregnancy related death" to permitclassification of deaths of women while pregnantor when recently delivered, even though localfacilities may not allow the cause of death to beidentified as "related to or aggravated by thepregnancy or its management." A pregnancyrelated death is thus defined as "the death of awoman while pregnant or within 42 days oftermination of pregnancy, irrespective of the causeof death." It. is likely, for instance, that somehomicides and suicides of pregnant or recentlypregnant women fall into this category, andaccidents may also be considered in this light,in so far as fatigue or reduced mobility in advancedpregnancy affects ability to avoid or surviveaccidents.'

A C P' L'HOURSM C THURIAUX

Division ot Epidemiological Surveillance andHealth Situation and Trend AssessmentStrengthening of Epidemiological andStatistical Services,

World Health Organisation,1211 Geneva,Switzcrland

I Chamberlain G. Vital statistics of births. BMJ 1991;303:178-81.(20 July.)

2 International conference for the tenth revision of the InternationalClassification of I)iseases, Geneva, 26 September-2 October1989. Wttrld Health Statistics Quarterly 1990;43:204-45.

3 Fortney JA. Implications of the ICD-I( definitions related todeath in pregnancy, childbirth or the puerpwrium. WorldHealth Statistics Quarterly 1990;43:246-8.

Nursing: an intellectual activitySIR,-For doctors to comment on matters con-cerning nursing risks touching a raw nerve-the"doctor's handmaiden" nerve-but the forthrightviews of June Clark, a professor of nursing,deserve discussion.' Doctors and nurses need each

BMJ VOLUME 303 7 SEPTEMBER 1991 579

other. They learn from each other. And if theydon't work well together it's the patient whosuffers. Both professions ought to be matureenough to discuss the problems of the other fromtime 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 gooddoctor if you don't consider the whole patient, asleaders of the medical profession like Lister andOsler emphasised 100 years ago.

Secondly, I fear that many doctors will not behappy with either of the suggested "two ways oflooking at nursing." Those who are said to look atnursing in the first way (which is described asthe more prevalent of the two perspectives) areaccused of believing that nurses do not require anunderstanding of why a task is necessary, how itworks, or what its effects will be. But surelynobody thinks this. Anyone with a grain of sensewants each member of a team to have as muchunderstanding as possible ofwhat is being done fora patient. Why else should nurses have lecturesfrom specialists explaining the thinking behinddifferent surgical and medical treatments?As regards Professor Clark's second way of

looking at nursing, everyone will agree with muchof what she says and with the progress towards aneven better trained, understanding, and skilfulnursing profession. But it seems to me that toachieve what she would apparently like to see forall nurses (examining and history taking, thoughtprocesses identical with those used in medicine,sophisticated cognitive and social skills, and so on)would mean that every nurse would have to gothrough a course of training very similar to that atmedical schools.We have all known nurses who, had they chosen

to do so, could have sailed through medical schoolwith flying colours. But there are many others-equally excellent and with equally good skill andjudgment in many circumstances-who would bethe first to agree that they could never compete orcope at this intellectual level and wouldn't want to.It doesn't help patients or anyone else to pretendotherwise. To be blunt, what is at stake here, itseems to me, is the credibility of those leaders ofthe nursing profession who brush reality under thecarpet and talk as if all nurses were broadly thesame in this respect.

THURSTAN B BREWINBray,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 areidentical with those in medicine, nursing alonefocuses on the "human response" and the "unique-ness of the individual"?'

Perhaps she has a vision of care provided bya multidisciplinary team led by nurses, withpsychologists providing counselling or behaviouralmanagement for problems that the nurse doesnot have time for and doctors available to signprescriptions and undertake manual tasks such aspinning femurs and performing tracheostomies.When I become helpless, whether from illness,

advancing years, or sheer rage, I hope that there willbe someone in this multidisciplinary team to soothemy fevered brow and, more importantly, to keepmeclean and dry, thus avoiding the bedsores that seemso common.

S BRANDONUniversity of Leicester School of Medicine,Leicester Royal Infirmary,PO Box 65,Leicester LE2 7LX


SIR,-Professor June Clarke's editorial on nursinginterested me as I am a qualified nurse as well as aqualified doctor. When I decided on a career innursing I had only two 0 levels. Fortunately, Ipassed the entrance exam and spent eight happyyears as a nurse. My training was intense andstimulating and had a strong element of discipline.I changed my profession not because I didn't enjoynursing but because I was searching for a differentsort of challenge.

I am saddened by the standards of nursing caretoday. Nurses no longer have time to sit andprovide that all important emotional support.They say that they are understaffed, but perhapsthey are too busy writing care plans and evaluatingthe care that they have been too busy to provide.

I agree that nursing requires a good intellect, butraising the entry requirement means that some realnurses are excluded. After all, had I applied 10years later to become a nurse I would not have beenaccepted with my two meagre 0 levels. I believethat standards are falling partly because of thisleaning towards academia. It is difficult to see howa degree in nursing produces better nurses whenthey spend more time in a classroom than atthe bedside. Of course good clinical research isneeded, but not at the expense of good nurseson the wards, where practical skills are vital.

If nurses want to be "clinical specialists" whydon't they change professions like I did? Believeme, the grass is not greener on the other side.

SALLY-ANN HAYWARDLondon 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 onrecognising nursing's intellectual component' Ithought of the women who, on several occasions,have promoted my "physical and mental comfort,healing, and recovery" and wondered what theywould have made of it. They would probably haveasked, "What on earth is she on about?"

Years ago I watched a district nurse restore mybadly burnt 80 year old grandfather throughconvalescence to renewed self confidence. A"considerable intellectual and emotional chal-lenge"? She would have been mystified. She wassimply doing her job and doing it superbly; and shewas 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 theworst kind of academic jargon. Sadly, this is not anisolated example-the whole article reeks of it.

I feel a sense of outrage on behalf of the womenwho nursed me, some of whom became valuedfriends of the family. If I was a young womanconsidering nursing today I would be frightened offby this article. I am afraid that many will be.

KATHLEEN NORCROSSBirmingham B29 7JA


HIV transmission duringsurgerySIR,-We should like to clarify certain issuesraised by Dr A G Bird and colleagues.' Theseremarks concern the case of the HIV infectedgynaecologist who agreed that the 1000 patients hehad operated on should be contacted.

Letters were sent to patients in the three districts.They were offered initial counselling by telephonehelpline and then encouraged to attend for furthercounselling and discussion at convenient centres.Alternative arrangements for counselling were alsocatered for, including home visits for those unableto take time off work or with transport difficulties,and an option of attending their own generalpractitioner instead of the organised counsellingsessions. The general practitioners had beenadvised separately about the nature of the incident.No patients were discouraged from having a

test, and the genitourinary clinics were used onlyfor counselling and testing within one district,where other facilities were not readily available.That many patients chose to have a test aftercounselling was in part related to their level ofanxiety on receipt of the letter. The role of thecounsellors was to offer impartial information andnot to persuade or dissuade patients from having atest.The Association of British Insurers, by recom-

mending a waiver note for patients taking the test,may have only confused its prevailing message. InApril 1991 a "statement of practice" was producedby the association, reiterating that a negative HIVtest in the absence of lifestyle risk factors would notjeopardise insurance premiums on any occasion. Awaiver notice was therefore not strictly necessary,but the machinery to produce this had in any casebeen put into operation well before the eventsbecame public.Whereas it may be claimed that the exercise

illustrated could have been used to provide evengreater epidemiological information, there is noevidence from the evaluation of work carried outlocally in the health authorities of any "collectivedenial" hindering epidemiological assessment.Indeed, our objectives included acknowledgmentof the potential risk (however small), sympatheticand confidential management of the individualsconcerned, and delivery of unbiased and correctinformation to the public.The success of the exercise cannot be judged by

the level ofHIV testing achieved, but rather by thedissipation of anxiety and uncertainty of all thoseinvolved.

S C CRAWSHAWR J WEST

West Suffolk Health Authority,Bury St Edmunds,Suffolk IP33 I YJ

1 Bird AG, Gore SM, Leigh-Brown AJ, Carter DC. Escape fromcollective denial: HIV transniission during surgery. BMJ1991;303:351-2. (10 August.)

Guidelines for doctors with HIVinfectionSIR, -In DrMichaelMorris'seditorialonAmericanlegislation on AIDS' the tired old guidelines fromthe General Medical Council are repeated yetagain: "It is unethical for physicians who know orbelieve themselves to be infected with HIV toput patients at risk by failing to seek appropriatecounselling or act upon it when given."

This will not do. AIDS may eventually kill theunfortunate surgeon who is HIV positive, but ifhe abandons his livelihood poverty, loneliness,depression, and debt will kill him sooner. Hisfamily surely have enough to cope with withoutlosing their house and facing a mountain of debt.

If those eminent people who formulate suchguidelines truly believe them then we must paythose whose counselling leads them to give up theirprofession the full rate for the job they are leaving.When the Ministry of Agriculture, Fisheries, andFood destroys livestock to control an outbreak offoot and mouth disease it pays the full market ratefor the animals it destroys, otherwise the farmerswould not always cooperate. If we really want to

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