General practitioners play a pivotal role within Britain's National Health Service (NHS). They are experts in diagnosis and carry out minor surgery in their offices. However, for any major surgery, patients are referred to a hospital, where they are placed under the care of a specialist. Women seeking birth control services can go either to their local general practitioner or to a family planning clinic for free contraceptive information and methods. Although general practitioners do not carry out abortions in their offices, women requesting an abortion must first visit their general practitioner to obtain a referral.
Given general practitioners' position as gatekeepers for abortions, their attitudes toward abortion and the law that governs it in Great Britain are very important. We set out to determine the attitudes of doctors and assess whether general practitioners' views were congruent with the smooth working of the Abortion Act.
Abortion in Great Britain
British law does not give women the same latitude to choose abortion as women in many other developed countries have. Under the 1967 Abortion Act, a British woman may obtain an abortion only after two doctors have certified that the procedure is necessary because the pregnancy would jeopardize her life, her physical health (i.e., the risk associated with continuing the pregnancy is greater than the risk associated with abortion) or her mental health; because the fetus is impaired; or because the woman is socioeconomically disadvantaged. She may then obtain the procedure at an NHS hospital, where she will pay no fee for the service, or in a commercial or private clinic approved by the Minister of Health.
In 1998, according to official figures, 12,424 residents of Scotland and 177,871 residents of England and Wales obtained abortions in Great Britain. Additionally, British physicians provided 5,891 abortions to women from southern Ireland, 1,581 to women from Northern Ireland and 2,059 to women from other countries. In England and Wales, 74% of abortions were provided through the NHS.1 Two major charities (Marie Stopes International and the British Pregnancy Advisory Service) provided 84% of abortions obtained outside the NHS.2 In recent years, these two organizations have also been carrying out abortions under subcontracts with the NHS.
General practitioners are allowed to provide women younger than 16 with birth control and abortion advice. However, eligible women sometimes are refused care. In a study of teenage mothers, some young women who had been refused birth control returned to their doctor pregnant shortly afterward. A doctor opposed to termination may put obstacles in the way, and calls to the British Family Planning Association's helpline indicate that such problems occur. For example, some doctors refuse to refer women to hospitals for terminations and may not tell them that they have the right to ask for another opinion.3
A random sample of 1,000 general practitioners was provided by the British Medical Association for a mailed survey conducted in 1999. Eighteen had retired or were deceased, and after three mailings, 702 (of whom 25% were women, 92% had children and 75% were aged 36-55) replied. Thus, we achieved a response rate of 71%, although some doctors did not answer all questions. A 1973 survey of British general practitioners' attitude toward abortion had a 59% response rate,4 while similar studies in Kansas and Idaho had response rates of 63-65%.5
The wording used in questions about abortion may affect both respondents' answers and how they are interpreted. We attempted to overcome this problem by asking some questions in a number of ways, using slightly different wording in each variation.6
Issues of Choice
The first question we asked was whether doctors consider themselves "broadly prochoice" or "broadly antiabortion." In all, 82% of the 663 respondents who answered the question characterized themselves as prochoice, while 18% said they were basically opposed to abortion. Eighty-five percent of general practitioners agreed that "if a general practitioner conscientiously objects to abortion, he/she should be required to declare this to a woman seeking access to abortion services." However, 10% disagreed, including 27% of antiabortion doctors and 8% of those who were prochoice.
A crucial question is whether general practitioners support a change in the law to give women the "right to choose" an abortion, or to obtain the procedure without restriction as to reason. We therefore asked respondents whether they agreed with the following statement: "The 1967 Abortion Act should be amended to provide a woman with the right to choose to have an abortion in the first 14 weeks of pregnancy, after consultation with a doctor." Sixty percent of the 659 physicians for whom we have data supported such a liberalization of the law. Doctors younger than 36 and those older than 55 were more likely to agree with the statement (67% of each group) than were those aged 36-55 (59%).
Given the current law requiring that two doctors be involved in the abortion decision, we asked respondents who they thought should take responsibility for the decision. Furthermore, as general practitioners were likely to have different views according to the pregnancy's gestation, we asked separately about pregnancies up to 12 weeks' gestation and those at a later stage. Within the first 12 weeks, 46% thought that the woman alone should make the decision; a further 7% thought it should be the woman and one doctor, and another 17% said that the woman should decide in conjunction with two physicians (Table 1). Only one in five doctors did not want women to be involved in the decision; these were largely doctors who were broadly antiabortion.
After 12 weeks of pregnancy, doctors took a more restrictive line. Only 21% thought that the woman should make the decision on her own. Nevertheless, half still thought that the decision should be made by the woman alone or with up to two doctors. Forty percent felt that doctors alone should make the decision.
The Law and NHS Abortions
In a question similar to that about the right to choose, we asked the doctors whether they agreed that "the 1967 Abortion Act, requiring the written consent of two doctors before any legal abortion can proceed, is appropriate and should remain unchanged." In a result that seems to contradict their support for a woman's right to choose, 63% agreed with this statement.
Three-quarters of the doctors agreed that "all women should have access to NHS abortion facilities," and one-quarter disagreed. To confirm this result, we asked whether they agreed with a similar statement, phrased in a negative way: "Abortion services should not be funded by the NHS." The results were similar; about one in five agreed.
We asked the doctors whether they thought that the 1967 Abortion Act "places an unreasonable burden of responsibility on the general practitioner." Twenty-six percent said that it does, while the rest disagreed.
Antiabortion Doctors' Views
We carried out further analysis of the views of the doctors who said they were broadly antiabortion. In this group, 21% supported women's having the right to choose. This finding suggests that they were espousing a position (originally put forward by Father Drinan, a Catholic priest in Boston) of general opposition to abortion but support for women's legal right to choose.7
Two-thirds (66%) of antiabortion doctors supported the 1967 Abortion Act, a similar proportion to that found among doctors who said they were prochoice (62%).
Another issue was whether doctors who stated that they were broadly antiabortion were in favor of abortion's being available through the NHS. Fifty-two percent of antiabortion doctors agreed that all women should have access to abortion through the NHS, compared with 82% of prochoice doctors; this difference was statistically significant (p=.001).
When the British Abortion Act was introduced, it represented an unprecedented liberalization of abortion law and was expected to have repercussions both for other countries' abortion laws and for women living in nearby countries with more restrictive laws. Initially, the major medical bodies, such as the British Medical Association and the Royal College of Obstetricians and Gynaecologists, came out against it. One of the chief reasons for their opposition was the belief that too much change would lead to women's telling doctors what to do.8 However, medical opinion soon changed, and results of surveys in 1970, 1972 and 1973 showed that general practitioners' attitudes toward the act were positive. In 1973, 52% thought that the law should be left as it was, 24% thought it should be changed to make abortion easier to obtain and 23% thought it should be changed to make abortion more difficult to obtain.9
Our findings show that the vast majority of doctors support women's right to have access to safe, legal abortion. The 82% who considered themselves prochoice is well above the figure of 56% in a study of general practice physicians in Kansas.10 A study in rural Idaho showed that almost four out of five physicians had a religious objection to abortion.11 (Although the U.S. studies were conducted in two conservative states, whose doctors may hold different attitudes than their British counterparts, no other studies that we are aware of are as comparable to our survey as these.)
Perhaps the most surprising finding is that two-thirds of doctors who were broadly antiabortion supported the Abortion Act. Apparently, while these doctors are not personally in favor of legal abortion, they nevertheless recognize it as preferable to having restrictive laws that could lead to a return to backstreet abortions or could force women to travel to other countries for treatment.
The British law lags behind those of other countries, where a woman may obtain an abortion in the early months of pregnancy with no restrictions as to her reason for doing so—for example, Austria, Belgium, Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Sweden and the United States. In most of these countries, women did not have the right to choose and abortion was largely illegal at the time the British Abortion Act was passed. As a result, some people argue that British women are denied rights that women in other countries have achieved.
We saw an apparent contradiction in the results that three in five doctors supported women's having the right to choose an abortion in consultation with a doctor, yet a similar proportion supported the act as currently constituted. A likely explanation for this is that many general practitioners who believe that women should have free choice give their patients the right to choose.
The finding that three-quarters of respondents felt that abortion should be available to all women through the NHS is striking and shows the high level of support for government provision of fertility control services. However, the results raise some concerns. A quarter of doctors thought that abortion was a burden on general practitioners, and a quarter of those who were "broadly antiabortion" did not believe that doctors need to reveal this stance to their patients. Perhaps not surprisingly, antiabortion doctors were also more likely than average to be opposed to NHS provision of abortions. So despite the overall positive response of general practitioners toward abortion rights, some areas are potentially problematic for women.
Antiabortion doctors may also create obstacles for women seeking abortions. The British Family Planning Association receives many complaints from women who report that their general practitioners have, for example, made them wait a week or more for the result of a pregnancy test or told them (wrongly) that they were too late for an abortion.12 Such tactics are likely to be especially problematic for younger, more vulnerable women, who may not be fully aware of their rights under the law.