Mistreatment of extreme morning sickness 'leading to abortions'

"Extreme morning sickness causes 1k abortions a year, study finds," The Daily Telegraph reports. The report states that poor treatment of some cases of extreme morning sickness (hyperemesis gravidarum) is leading some women to terminate their pregnancy, despite there being safe and effective treatments available.

While morning sickness can be unpleasant, hyperemesis gravidarum (HG) can be extremely debilitating. It can cause feelings of constant nausea, frequent vomiting (some women have reported vomiting up to 50 times a day) and dehydration. Left untreated, it can even be life-threatening.

The "one thousand" figure quoted by the Telegraph comes from an unpublished survey reportedly finding that up to 10% of women with severe morning sickness terminate a pregnancy because of this. We are therefore not able to comment further on the representation of this survey or the validity of this figure.

What is the basis for these reports?

In a joint report called "I could not survive another day", The British Pregnancy Advisory Service and Pregnancy Sickness Support recount women's experiences of severe pregnancy sickness.

The report aims to improve treatment and tackle stigma for women with severe pregnancy sickness by outlining the experiences that led some to have an abortion. The report takes the form of a referenced discussion supported by anecdotes. However, no methods are given in the report, so we cannot know how the selected research has been identified, or whether all relevant information has been considered. We also don’t know how representative the sample is of all women with severe morning sickness, and it is not possible for us to verify the information they have given.

Sickness in pregnancy

Sickness in pregnancy is common. Around 7 out of every 10 pregnant women experience nausea and/or vomiting, and this doesn't just occur in the morning. The medical term for morning sickness is nausea and vomiting in pregnancy.

For most women, this improves or disappears completely by around week 14, although it can last longer for some women.

However, some pregnant women experience severe nausea and vomiting. They might be sick many times a day and be unable to keep food or drink down, which can have a negative impact their daily life. Many women with this condition are unable to leave their house, go to work or look after their other children.

What is severe pregnancy sickness?

Severe pregnancy sickness, called HG, is a severe pregnancy complication characterised by extreme nausea and vomiting. Symptoms in addition to the nausea and vomiting can include ptyalism (excessive saliva production), headaches, heightened and warped sense of smell, and extreme fatigue.

Poor management of HG can lead to complications, including but not limited to, dehydration and malnutrition, tears of the food pipe, burst blood vessels, pressure sores, deep vein thrombosis and placental abruption. In addition to the physical complications, HG can lead to depression and social isolation, as well as financial and relationship problems for those experiencing it, and women feel they are less effective parents due to the condition. These complications can lead to post-traumatic stress disorder, and the condition is known to limit family size.

What evidence does the report discuss?

The report is based on the experiences of 71 women who had terminated a pregnancy while suffering HG over the past 10 years. The report documents their experiences and discusses what can be done to improve care for women in this situation and better support their choices.

Most women surveyed (over 85%) believed that healthcare professionals did not understand their condition or believed how ill they were. For the majority of women, it was the impact that HG had on their ability to care for their existing children that was a key factor in their decision.

A significant proportion of women who ended wanted pregnancies were reportedly not offered the full range of treatment options. They were said to be "expected either to put up with the sickness or undergo an abortion".

There were also said to be struggles accessing medication. The report suggests that doctors’ previous awareness of the thalidomide tragedy may have led them to fear of medicating during pregnancy. Thalidomide was marketed first as a sleeping pill, then as an aid for morning sickness during the 1950s. It was soon found to cause severe and often fatal birth defects.

They say that most effective medications for nausea and vomiting are not licensed in pregnancy because pharmaceutical companies usually exclude pregnant women from drug trials, and doctors who prescribe medication for pregnant women do so off-label.

Stigma and misapprehensions were documented. A number of women surveyed commented on the difficulty talking about their decision, fearing judgement for terminating a wanted pregnancy "just for morning sickness".

How accurate is the media reporting of the study?

The media reporting was generally accurate and represented the information given in the report. Many quoted figures suggesting that around 10,000 women suffered HG, and 10% of these decide to terminate their pregnancy as a result. This figure comes from an unpublished survey reportedly finding that up to 10% of women with severe morning sickness terminate a pregnancy because of this. We are therefore not able to comment further on the representation of this survey or the validity of this figure.

What recommendations were made?

The report says that any woman who has made an appointment to discuss her symptoms should have her concerns taken seriously and any risks of medication must be weighed against the larger picture of the risks both for mother and baby of not treating HG, especially if symptoms become so bad that the mother considers terminating the pregnancy.

The report says the stigma and guilt that surrounds abortion for severe sickness should also be confronted. Many women continue to "blame themselves for being unable to carry their pregnancy to term, or feel that they should have fought harder to get help".

The report concludes: "No woman should ever be judged, feel ashamed or a failure for deciding that abortion is the best course of action for her, or pressured into accepting medication when she believes ending the pregnancy is what she needs to do. But women with pregnancies they wish to keep deserve prompt access to treatments that may enable them to do just that."