It is reported that the government is proposing to make further amendments to the Maltese law on abortion. Unfortunately, at the point this article is being drafted it is not known exactly how this new amendment will be framed, but the proposal has been widely tracked in the local press.
Previously, the government’s proposed amendment was that abortion would be lawful if the patient were “suffering from a medical complication which may put her life at risk or her health in grave jeopardy”.
This was calculated to suggest that the law was meant to allow abortion during late pregnancy when there was a dilemma between saving either mother or child, and the complication was a complication of late pregnancy which might become grave during the time of delivery or thereabouts, thus satisfying the so-called ‘double effect’ principle. In practice, such complications are very rare.
However, now, the specification suggested in the new further amendment, that abortion will only be legal up to 24 weeks, changes the proposed amendment entirely.
It focuses on the first 24 weeks of pregnancy, when the foetus is not viable, and the likely conditions which the mother might suffer from, and which might deteriorate seriously. These are chronic conditions which the mother would have been suffering from before becoming pregnant, such as diabetes, hypertension, renal disease, epilepsy and various mental health conditions including depression, anxiety disorders, schizophrenia and bipolar disorder and diseases of pregnancy itself, such as pre-eclampsia and diabetes of pregnancy.
Now, all the international guidelines for treating these diseases recommend in great detail the optimising of treatment for these women with the aim of producing healthy mothers and babies. This could include, especially in mental health, adjusting medication to ensure the best possible health of the babies.
The guidelines include the Maudsley guidelines on mental health 2018; the clinical practice guideline on pregnancy and renal disease by Wiles et al, 2019; the NICE guidelines on women of childbearing age with epilepsy 2022; the NICE National Institute for Health and Care Excellence Diabetes in Pregnancy: management from preconception to the postnatal period 2020; the NICE National Institute for Health and Care Excellence Intra-partum care: existing medical conditions and obstetric complications 2020; the NICE guideline on Hypertension in Pregnancy: diagnosis and management 2019; among others.
It is for the minister of health to ensure that best practice is followed and that both mothers and the babies they are carrying do well, and not to abort the babies. An explanation regarding the law in the UK is necessary to inform the present debate.
There is relatively little demand from persons with common chronic diseases for abortion up to 24 weeks of pregnancy- Mark Agius
It is true that in 2021, 98 per cent of abortions in England and Wales (209,939) were performed on the grounds that “the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”.
It is also true that of these, “the vast majority (99.9 per cent) of abortions carried out on this ground were reported as being performed because of a risk to the woman’s mental health”. However, these persons were not reported as suffering from depression, anxiety, bipolar disorder or schizophrenia or other important mental health condition.
Instead they were all classified as having F99 (mental disorder, not otherwise specified) under the International Classification of Disease version 10 (ICD-10). “Mental disorder not otherwise specified” means that they had minor mental problems related to them being pregnant and so the patient had requested a termination of the pregnancy. They could therefore not be said to be suffering from an important mental illness.
Therefore, if this very large number of persons were discounted as suffering from serious mental illness, it follows that there are very few persons in England in 2021 who required an abortion for any serious illness within the first 24 weeks of pregnancy. This is likely to be in part because of the present excellent guidelines I have discussed above.
This calculation needs to be clearly understood when evaluating the necessity of introducing a law in Malta to make abortion legal up to 24 weeks of pregnancy – put simply, it is clear that in England and in countries like Malta which tend to follow English systems and methods of medical training, there is relatively little demand from persons with common chronic diseases for abortion up to 24 weeks of pregnancy, and such patients are most likely, with good medical care, to have successful pregnancies.
Therefore, the only large group of persons who are likely to request termination of pregnancy up to 24 weeks of pregnancy are those, as in England, who are classified as having “F99 mental disorder, not otherwise specified”, and this classification does not represent serious illness but rather those persons who, for various reasons of discomfort, go to their doctor and request an abortion of the pregnancy, which, in effect is ‘abortion on demand’.
Mark Agius is a retired doctor. He is a writer on medical management, the doctor-patient relationship and psychiatry. He has taught at Cambridge and Prague medical schools.