A submission to the NICE call for evidence regarding termination of pregnancy guidelines currently under review
The UK is currently home to at least 3.4 million Muslims  who, to varying degrees, will refer to Islamic jurisprudential and ethical teachings to inform/guide their healthcare decisions, including that of termination of pregnancy (TOP). It is therefore pertinent for TOP providers to be aware of this system of ethics used by some of their patients, in order to effectively engage in patient-centred shared decision making with them.
TOP is not permitted in Islamic law, except under legal exception [2-5]. The applicability of such exceptions depends on the gestational age of the foetus, as the gestational age at which ensoulment is believed to occur dictates the foetus’ subsequent full legal status. There is a difference of opinion among contemporary Muslims jurists, of differing legal schools of thought, about when ensoulment occurs with two major opinions being at 120 days gestation (or 19 weeks post-LMP ) and 40 days gestation (or ~8 weeks post-LMP).
Before ensoulment, TOP is permitted to avoid intolerable difficulty or severe loss/hardship associated with the pregnancy or rearing the child thereafter. Common examples would include TOP to prevent threat to the life of the mother, severe injury (or substantial risk thereof) to the physical/mental health of the mother, severe hardship associated with rearing a child with a congenital abnormality (judged on a case-by-case basis) and severe hardship associated with the social circumstances of the woman’s pregnancy (although financial difficulties are generally not acceptable in isolation). After ensoulment, some Islamic jurists may permit TOP under certain situations where the mother’s life is at risk. In any case, where a patient indicates Islamic law to be influential to their decision on TOP, consultation of that patient with a qualified and experienced Islamic scholar for the purposes of providing individualised, case-by-case guidance may be appropriate and helpful.
Furthemore, Islamic law does not permit Muslim healthcare professionals, even whilst living and working in the UK, to approve or conduct TOP procedures in patients (Muslim or otherwise) requesting TOP not fulfilling Islamic legal criteria.
Apart from Islamic jurisprudential teachings, Muslim patients’ TOP decision may also be influenced by ethical/theological beliefs [7, 8], including about the wrongness of abortion from day one, fate and acceptance of God’s will, how it is not their decision to interfere in God’s creation, the blessings of caring for a handicapped child, the reward associated with undergoing hardship in pregnancy and thereafter, the belief in hardship being a test from God, fear of God’s punishment for terminating a pregnancy due to putting one’s own interests before that of an unborn child, and, the importance of self-sacrifice to bring a child, albeit through difficulty or illness, into the world . These considerations may be influential for a Muslim patient in deciding to continue her pregnancy, despite Islamic jurisprudential edicts permitting TOP in her case.
Furthermore, cultural (non-religious) factors may also affect Muslim patients’ decisions for TOP. This may include a perceived stigma from their local community or pressure from their partner, spouse or family members (both in favour of or against TOP). It may also include secular beliefs about the immorality of bringing children into the world with severe foetal anomaly and subjecting them to suffering.
Apart from the above, Muslim patients’ decision to terminate a pregnancy will also, naturally, be influenced by factors that patients of other (or no) faith are also influenced by, including ease of access to TOP services, information about the procedure, concerns regarding safety, confidentiality and the care they will receive, their emotional/psychological health after the procedure, and the subsequent support available to guide their reproductive decision making, including the use of contraception.
Importantly, just because a patient appears Muslim, or admits to belonging to the Islamic faith, should not prompt healthcare professionals to assume that such patients will follow the letter of their faith. It is therefore paramount that healthcare professionals are sufficiently trained to sensitively gauge and appreciate the variety and interplay of factors that a Muslim patient will consider, including (but not limited to) the teachings of their faith, in order to discuss the various options available to them (including the continuation of pregnancy).
In the context of these various factors that influence Muslim patients (and Muslim doctors’) decisions to participate in TOP, the British Islamic Medical Association offers the following responses to the recent draft NICE guideline on Termination of Pregnancy, published 12 April 2019.
Information should be tailored specifically to account for the beliefs, values and concerns of Muslim patients, in a sensitive manner, to aid them (and those whom the patient freely chooses to accompany them, including their spouse/family members) to engage in a process of informed decision making, including the option of continuing pregnancy and its implications
In cases where a Muslim woman does choose TOP, prompt referral is essential due to the time limit of ensoulment under which the Islamic legal exception for TOP is likely to apply, should the patient see this as influential to her decision.
Muslim doctors and trainees (and other healthcare professionals, including students, nurses and midwives) may conscientiously object to refer, approve or participate in TOP procedures/services for both Muslim and non-Muslim patients, regardless of circumstances, gestational age or the fulfilment of Islamic legal criteria. Services should therefore be designed in a way which do not pressurise Muslim healthcare professionals against their right to conscientiously object, but also do not delay TOP service provision to women who will nonetheless seek an appointment/referral through another healthcare professional or, self-refer.
Muslim clinicians should however provide care for women suffering from complications due to TOP, whatever the reason or grounds for that TOP.
Minimal delay in the provision of TOP for Muslim patients is essential, due to the legal time limit of ensoulment. Healthcare professionals should therefore enquire about whether a Muslim patient has any specific time limits in mind which would affect her TOP decision and ensure swift access to TOP services accordingly, including prioritisation.
It is a reality that the majority of TOPs in the England are carried out under the Royal College of Obstetricians and Gynaecologists (RCOG) Ground C during the first trimester, due to unwanted pregnancy, though not necessarily any real or foreseeable risk to the mental health of the pregnant woman . Furthermore, the British Medical Association (BMA) also issued that “Given the risks associated with pregnancy and childbirth, and the risks of a woman having to continue a pregnancy against her wishes (compared with the minor risks associated with early medical abortion), there will always be medical grounds to justify termination in the first trimester”. On this, Islamic law requires the presence of intolerable difficult or severe hardship/loss regarding the mental/physical health of the pregnant woman to justify a TOP. Therefore, the technique of utilising relative risk does not hold legal weight in Islamic abortion law. For this reason, it is not unlikely that a proportion of Muslim clinicians would conscientiously object to partaking in TOP procedures in (the majority of) women requesting TOP on the grounds of unwanted pregnancy, even if it be integral to their speciality training curriculum. In this regard, NHS Trusts, higher educational institutions, Royal Colleges, and postgraduate deaneries involved in speciality training should provide clear information and guidance on the process of conscientious objection. Furthermore, an environment of tolerance for objecting trainees should prevail and under no circumstances should trainees perceive disadvantage in obtaining speciality training posts due to a foreseeable (or actual) decision to object to partake in TOP.
Muslim patients may freely and wilfully request the inclusion of their spouse or family members in their TOP (or continuation of pregnancy) decision. Healthcare professionals should respect and facilitate this, and not stigmatise women for their decision to include others in their reproductive choice. Healthcare professionals must also not apply pressure on Muslim women to partake in their decision alone, if that is not what they want. Similarly, healthcare professionals should be conscious of third parties seeking to influence the decision of a Muslim patient against her will and should provide adequate safeguarding in such a situation.
Healthcare professional should also not stigmatise or judge Muslim women for wanting to continue with their pregnancy based on underlying theological beliefs, even if they do not sit with the personal viewpoints of the healthcare professional involved in that shared-decision.
Information provision should not only be limited to the experiences of women who have had a TOP but should also include information about women considering TOP (for various reasons), as well as information on the experiences of women who chose to continue with their pregnancy despite initially considering/deciding on a TOP. This is in lieu of the fact that women should be aware of their freedom to change their decision at any time during the process. It is essential that information provision from all healthcare professionals involved in the TOP care pathway is holistic and includes information on the continuation of pregnancy, as opposed to being limited to the experiences and options of the type/time of TOP procedure, and the implications thereafter.
It is essential that healthcare professional involved in TOP-decisions with women first gauge the extent to which a woman wishes to be informed about the intricacies of the process. This is to avoid undue distress to the patient, in what already may be a difficult and sensitive decision.
Muslim women may wish for foetal remains to be buried according to Islamic funeral rites. Healthcare professionals should therefore adequately explain the process of discharging foetal remains and do so in a manner sensitive of the status that a Muslim patient (and her family) may award to the deceased foetus.
It has been shown that there is a higher incidence of foetal anomalies in pregnancies borne to British Muslim women, thought to result from their higher incidence of cousin marriages amongst certain ethnic and cultural groups within the Muslim community [11, 12]. For this reason, consideration of TOP due to foetal anomaly may be more common among Muslim women than the general female population. In this regard, we recommend that:
· Pre-natal screening for foetal anomalies should not be withheld from Muslim women, just because they are unsure about whether they would have a TOP. In this regard, all patients have the right to information about their pregnancy, so that they can make as well-informed choices as possible.
· The provision of information about the nature of the anomaly, whether it directly causes risk to the health of the Muslim patient during her pregnancy, or the expected responsibility (i.e. hardship) associated with supporting a disabled child is essential. This is because such information forms the basis of the Islamic legal exception permitting TOP in the case of foetal anomaly, thus is likely to be influential to a Muslim patient’s decision on TOP due to foetal anomaly.
· Muslim patients should be made aware of the support available to them should they wish to continue with a pregnancy involving a foetal anomaly. Healthcare professionals should also engage in discussion about the patient’s social support structures in this regard.
· In cases of familial diseases, we recommend genetic/diagnostic tests be offered to at-risk, pregnant Muslim women as early as possible, allowing them to consider TOP in good time before the time of ensoulment.
In the case of a surgical TOP, Muslim women, due to various religious or cultural factors, may request a female doctor to carry out their procedure. Some Muslim patients may see this as more important than others. TOP services should therefore attempt, where possible, to facilitate this request, including referral to other TOP providers.
In the context of wanting to preserve (all parts of) foetal remains from a TOP for an Islamic burial, Muslim women may have specific sensitivities about how to handle said foetal remains during an at-home expulsion. In this regard, healthcare professionals should fully explain to the patient what to expect during an at-home expulsion, as well as the option of medical termination under hospital admission purely for the purposes of more sensitive handling of foetal remains and respectful discharge of said remains to the patient/family thereafter.
TOP providers should provide the option of in-house counselling or psychological interventions, as opposed to referring to community mental health services, in the interest of maintaining a woman’s confidentiality and providing prompt support.
Apart from counselling, Muslim women may request access to Muslim chaplaincy services to provide support before, during and after TOP. We recommend that TOP service providers explore links with approved local hospital and community Muslim chaplains and establish a referral pathway for women who request it.
It is also essential that both male and female Muslim chaplains are there to listen and offer spiritual and pastoral care without judgment and in a confidential manner, whatever the reason for the TOP, or the week of gestation that the TOP was carried out at.
We, the British Islamic Medical Association, recommend the commissioning of research into the development of culturally and religiously sensitive TOP care pathways for Muslim women. This could include, but is not limited to:
· What factors affect a British Muslim woman’s decision to terminate her pregnancy?
· What barriers, if any, exist to British Muslim women accessing TOP services?
· Do British Muslim women’s experience of TOP services evidence that they are provided in a way which reflects and accounts for their concerns, beliefs and values?
· To what extent would the sensitivity of the 18-21 week foetal anomaly scan be affected, were it to be offered earlier at 14-16 weeks to Muslim women, allowing them time to consider TOP (before 19 weeks post-LMP) for other foetal anomalies not screened for during the early pregnancy (10-14 week) scan?
 Hanafi, Shafi’I and Ja’fari schools.
 Maliki and Hanbali schools
 Although some other jurists have also argued 80 days or 5 months.
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10. BMA, The Law and Ethics of Abortion, November 2014
11. Sheridan E. et al. Risk factors for congenital anomaly in a multiethnic birth cohort: an analysis of the Born in Bradford study. Lancet. 2013. 382(9901):1350-9
12. Corry P. C. Consanguinity and Prevalence Patterns of Inherited Disease in the UK Pakistani Community. Hum Hered. 2014. 77:207-216