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Is this the end for independent midwives?

January 17, 2017

Malpractice insurance problems

In Britain midwives and obstetricians care for normal and abnormal pregnancies respectively and are regulated by the Nursing & Midwifery Council (NMC) or the General Medical Council (GMC). In the NHS, they work on broadly similar pay scales, (midwives £22 – £99K, obstetricians £26 – £102K), albeit with more of the latter at the upper points.

Not so in the private sector.  Celebrity obstetricians cater to princesses and footballers’ wives in The Portland or St Mary’s Lindo Wing, and make serious money, while most independent midwives, driven by a desire to encourage natural childbirth, or to help mothers let down by the NHS, charge low fees for their 24/7 availability. Few earn even as much as their NHS sisters, making it difficult to afford personal indemnity insurance.

The issue came to a head for obstetricians about 20 years ago.  Until then all doctors paid the same premium, a few hundred pounds, but in the early 1990s birth injury awards rose steeply and insurance companies introduced differential premiums; for obstetrics about £10,000 a year. The taxpayer picked up the tab; crown indemnity for all NHS doctors. The Duchess of Cambridge’s private obstetrician still has to pay a whacking great premium, but he can afford it!

NHS midwives had always had crown indemnity. Independent midwives had a modestly priced insurance scheme through their Royal College and rarely got sued; few of their patients would have dreamt of it. But as medical malpractice claims, often backdated many years, went through the roof, underwriters got nervous and ramped up premiums. For cover equivalent to that in the NHS, the premium would now be about £1,000 per birth supervised; more than most independent midwives could afford.

Some gave up. Others put their homes in their partner’s name, so if they got sued for millions, they could declared bankruptcy. So long as they were open about their lack of cover their patients could either go back to the NHS, or take the risk of missing out on compensation. As far as I know things went OK – patients don’t like suing individuals, and lawyers follow the money – until a few years ago, when the Department of Health ruled that they must have insurance. This seems to have been partly to comply with an EU directive (click here) and partly in response to a review by a fellow called Findlay Scott (click here), although Scott simply recommended how best to achieve the politically driven aim of mandatory insurance.

The independent midwives association, IMUK, found an affordable scheme. The details seem to be secret; at least I’ve not seen them. Presumably the levels of cover are rather low. Soon someone persuaded the NMC to investigate the scheme’s financial viability. Some say it was the Department of Health, others disgruntled patients who’d missed out on damages. I’ve even heard it claimed that private birth centres, hoping to do down the competition, were behind it. We may never know. But whatever the cause, the NMC, prodded into action, has just ruled (details here) that the IMUK scheme is underfunded, and that midwives depending on it face removal from the register. Eighty or so independent midwives must close shop forthwith, and send their patients back to the NHS.

Views on this matter depend partly on whether you believe that informed adults should be allowed to take risks, go rock climbing, smoke cigarettes, or give birth at home under the care of an uninsured midwife, without the nanny state interfering. The answer is of course yes, unless your action endangers others. Rock climbing is fine but smoking in an enclosed public space is not. What about endangering your unborn baby?

To over simplify. The legal (and many feminists’) view is that, unless the mother deems it so, an unborn baby is of no consequence up to the moment of birth; she can smoke, go rock climbing, even abort it, and it’s no-one else’s business. An informed adult woman should be free to have a home vaginal breech birth after Caesarean (HVBBAC) under the care of of her uninsured neighbour trained on Wikipaedia!  I think this is broadly the view of Birthrights, the human rights in childbirth organisation (click here), who buttress their philosophical stance with the claim that if independent midwives are forced out of business, some women will give birth without any health professional present.

Others argue that the baby is the person most likely to get damaged. It deserves protection not only from incompetent midwives, who should be forced to get proper insurance, but also from feckless parents who take the risk of employing uninsured midwives. If independent midwives are driven out of business, and unhappy mothers get forced back into the NHS, or deliver alone, that’s tough. Get over it.

I fear the latter view will prevail; we Brits seem to rather like collective government-mandated solutions to our problems. But my sympathies are with Birthrights. The case of HVBBAC above, is fictitious. Women don’t choose independent midwives for trivial reasons, and rarely take unreasonable risks with their baby. Even if things turn out badly, the baby will still get the full panoply of UK health and social care, albeit without any extra financial compensation.

But women must be fully informed about their midwife’s insurance cover, or lack of it. If I can’t find out the details, how can a mother? IMUK’s website simply says “All members hold mandatory professional indemnity insurance” (click here). That’s not good enough.

The ramifications of this extend beyond the tiny numbers directly involved. Independent midwives are a huge benefit to the rest of us who work in that monolithic monster, the NHS.  They make us question our assumptions, keep us on our toes, and look after the women we’ve failed.

Come on IMUK. Be open and honest about your level of indemnity cover. Please don’t price them out of business NMC.

Jim Thornton

Walking the Dog

December 23, 2016

By Howard Nemerov

Most animal poems are sentimental tosh, but there are exceptions. A Blessing by James Wright is one. Here’s another.

I’m not sure it’s even really about dogs. We all think shit is interesting, and Connected by love and a leash and nothing else must be about something else. Showing who’s master I guess.

Walking the Dog

Two universes mosey down the street
Connected by love and a leash and nothing else.
Mostly I look at lamplight through the leaves
While he mooches along with tail up and snout down,
Getting a secret knowledge through the nose
Almost entirely hidden from my sight.

We stand while he’s enraptured by a bush
Till I can’t stand our standing any more
And haul him off; for our relationship
Is patience balancing to this side tug
And that side drag; a pair of symbionts
Contented not to think each other’s thoughts.

What else we have in common’s what he taught,
Our interest in shit. We know its every state
From steaming fresh through stink to nature’s way
Of sluicing it downstreet dissolved in rain
Or drying it to dust that blows away.
We move along the street inspecting shit.

His sense of it is keener far than mine,
And only when he finds the place precise
He signifies by sniffing urgently
And circles thrice about, and squats, and shits,
Whereon we both with dignity walk home
And just to show who’s master I write the poem.

Howard Nemerov

Symphysiotomy in Ireland

December 13, 2016

The Clark report

A dozen or so years ago a group of people in Ireland got the idea that between the 1940’s and 80’s Irish obstetricians had systematically abused young women by inflicting an outdated and cruel operation on them; dividing the ligaments joining the pubic bones to enlarge the pelvis and facilitate birth. The claim was that although doctors knew symphysiotomy was agonisingly painful and had a high rate of life-altering complications, they did it in preference to Caesarean section as a form of punishment for women pregnant out of wedlock. As a result of their Catholic religious zeal, hundreds, maybe thousands, of women suffered terrible lifelong injuries. Click here for the main pressure group’s website.

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A few women went to court for civil redress, but with little success; there was little objective evidence of serious injury. Nevertheless a campaign for “no fault” compensation gained momentum, and at least four enquires were set up. Two ran into the sand under partisan criticism, but two others (available here) suggested there might be a problem and, in view of the difficulties of pursuing negligence claims so long after the event, recommended a state redress scheme overseen by a high court judge, Maureen Harding Clark.

Her report (click here) (alternative here the-surgical-symphysiotomy-ex-gratia-payment-scheme-report) was released on 19 October. She confirmed that symphysiotomy was indeed used more often in Ireland than other similar developed countries; the rationale being unavailability of contraception and the risks of repeat Caesareans for women with large families. The prohibition on contraception was driven by Catholic teaching, but Clark found little evidence that the symphysiotomy itself was done for religious reasons or to punish single mothers. Rather she unearthed some evidence to the contrary; the doctors used the procedure sparingly, and were driven by a desire to avoid the morbidity and mortality associated with Caesarean section in that era.

“While evidence of religious motivation […] is found in the 1949 NMH [national Maternity Hospital] Annual Clinical Report and in a study by A P Barry, Master of the NMH, it was absent from any other report although the issue of large families and no contraception was commonly raised during the annual discussions known as the Transactions Meetings. There appeared to be a high degree of support for Catholic teaching on contraception among those present and contributing to discussion.” (para 32)

Perhaps now is rather late to second guess motivation. Obstetricians like me* will be more interested in learning what complications actually occurred, particularly in the long term.  This is not straightforward because Judge Clark’s primary interest was not in causation; her criterion for making an award was any contemporaneous documentation of any injury or symptom which could plausibly ever be an effect of symphysiotomy. But let me try. Of 589 alleged cases submitted for review, at most 404 had actually undergone symphysiotomy.

“It is highly probable that several applicants received awards in error. In 3 extremely troublesome cases, notwithstanding very extensive investigations, even with the assistance of specialists, I was simply unable to exclude the possibility that the applicants had undergone a symphysiotomy procedure. In those cases, the birth records were either incomplete or unavailable and medical evidence was unsatisfactory. I formed the view that it was better to err in making an award to an elderly applicant convinced of the truth of her claim than to be wrong and refuse an award to a deserving applicant. In approximately 6 other cases, earlier reliance on scar and in one case, radiology evidence led me into error. I take responsibility for my errors. In 2 cases where reliance was placed on medical opinion, records which were not available at the time of assessment subsequently became available from stored archives. They confirmed earlier suspicions that no symphysiotomy procedure had been performed.”

The true number of cases is therefore likely to be 393 (404-11). About 100 of these agreed that they had suffered no injury beyond the immediate pain of the procedure, and were given “compensation” of £50K. This left about 300 women who claimed to have long term injury. Of these, Clark eventually judged that 142/404 (35%) had suffered something; excessive separation of the pubic bones, pubic pain, pelvic instability, incontinence, psychological/psychosexual difficulties or sacroiliac pain. On the face of it a high rate, but this assumes all documented problems which could plausibly be an effect of symphysiotomy, were caused by it. In the real world pubic bones separate spontaneously during birth, separation is often asymptomatic, and other symptoms are common anyway, particularly after forceps, which many women had also undergone. Clark, realising this, writes:

“No general pattern of immediate or developmental injury was seen. The evidence did not confirm that symphysiotomy inevitably leads to lifelong pain or disability or those symphysiotomy patients aged in a manner which was different to those of non-symphysiotomy women. The majority of applicants who underwent symphysiotomy made a good recovery and went on to have normal pregnancies and deliveries and to lead a full life. Most applicants had at least 4 normal deliveries after the symphysiotomy. A small number of applicants suffered from pelvic pain and a slightly larger group [24 cases] from urinary issues. Whether the conditions were associated with prolonged labour, the use of forceps, parity or the symphysiotomy procedure or a combination of all three was not possible at this remove to determine. It was noted that many symphysiotomy procedures were carried out after a ‘failed forceps’.” para 22

Here is judge Clark describing her process for evaluating if incontinence had resulted.

“I first determined that the test for finding incontinence constituting significant disability would be evidence of any mention of any degree of incontinence or urinary tract infections on the available notes relating to the symphysiotomy birth and the next pregnancy. The cases were so few that the threshold was lowered again to any mention of incontinence or multiple urinary tract infections in GP records in the first decade following the symphysiotomy birth. Even when the threshold was set at the low level of any possible temporal association with symphysiotomy, little was found to match complaints in the majority of cases.”(para 179)

In only five of the 24 cases of urinary incontinence associated with symphysiotomy was there a close temporal or other relationship such that causation was likely.

“[These five] had suffered bladder / urethral damage or fistula at the time of symphysiotomy. The injury was identified within hours of the symphysiotomy and repaired at the first opportunity. All five applicants were thereafter predisposed to urinary tract infections and in one case, continuing incontinence.” (para 24).

Here is Judge Clark on unstable pelvis/ arthropathy etc.

“The appearance of the pubic symphysis was abnormal in 80 cases with variable degrees of other musculo-skeletal conditions. 12 applicants demonstrated what were described as grossly
abnormal findings. The abnormal radiological findings included continuing diastasis (separation of the bones of the symphysis) of 15mm or more and included a small number of cases of severe sclerosis, fluid in the joint, large osteophytes, capsular hypertrophy, vertical misalignment or the presence of bone fragments. Sometimes the wide diastasis was associated with sacroiliac joint arthropathy but in several instances, the sacroiliac joints were normal. There were very few cases of pelvic instability, that is, evidence of movement in the joint. For the purposes of the Scheme, if the appearance of the joint was abnormal, this was always taken as evidence of either inflammation or movement at the joint occurring in the immediate aftermath of the symphysiotomy procedure. There were very few cases of hip degeneration at an inappropriate age and no documented cases of difficulty with walking after about 3 months.” (para 23).

To summarise, 404 (or 393) symphysiotomy procedures resulted in five cases of urinary tract damage, one of whom was left with incontinence, and, despite 80 women ending up with radiological signs of pelvic damage, no documented cases of difficulty with walking after about 3 months. Until the campaign drew their attention to the “harms” of symphysiotomy, the women who had undergone it had gone on to have more children, to have backache, sexual difficulties and troublesome periods at pretty much the same rate as their sisters. Nevertheless:

“On countless occasions, it seemed that once the symphysiotomy procedure was identified (usually in 2003/2004), new complaints previously absent from the records spanning decades were made and every health ailment was attributed to symphysiotomy.” (para 112)

Lawyers and psychiatrists dealing with other types of alleged historical abuse will be interested in the 185 women who had not undergone symphysiotomy. Experimental psychology has shown that false memory is real – if you see what I mean – but no-one knows how common it is in real life. Here is Justice Clark:

“Almost a third of applicants did not undergo symphysiotomy. This is a very significant number. Even if applications made on behalf of those who simply did not know whether they underwent symphysiotomy or where  family members thought their mother might have undergone such a procedure are excluded, the number (185 in total) still begs some examination and scrutiny. How could these don’t knows and so many other women wrongly believe that they had undergone this procedure with its highly publicised adverse effects?” (para 220)

“It is very possible that advertising by some legal firms to encourage women who “may” have undergone symphysiotomy to bring claims resulted in many of the unfounded applications. The applications may have been submitted simply in order to comply with the application time period before the necessary supporting medical records were obtained. While there may have been a vexatious element to their applications, many of these applications were withdrawn once their records were examined. In others, misunderstanding between episiotomy and symphysiotomy was evident.” (para 224)

“The publicity surrounding the activism for the Government to set up a compensation scheme for symphysiotomy victims was quite intense. There can hardly be a person in Ireland who has not been exposed to reports of the procedure described as butchery akin to Nazi medical experimentation;, aggravated sexual assault; a form of female genital mutilation causing life long disability, chronic pain, mental suffering and family breakdown and much more. These reports have been so persistent and frequent that they have created something akin to a knee jerk reaction to the word symphysiotomy. It is viewed as a procedure synonymous with barbarism and pain; but not just barbaric and painful but unnecessary and unwarranted, creating a legacy of countless victims whose lives were permanently ruined. […] Some of those […] women who did not undergo symphysiotomy have been prominent, vocal and long time activists as victims of symphysiotomy. (para 225)

“After much thought, I concluded that it is very probable that the combination of a traumatic birth experience and exposure to other women’s stories has created a self convincing confabulation of personal history. Another inference is that the possibility of financial payment has influenced suggestible women and their family members into self-serving adoption and embracing of the experiences described by others or in the media and created psychosomatic conditions.” (para 226)

Obstetricians and lawyers will be studying this report for some time.

Jim Thornton

*Disclosure. Over a four year period in rural Kenya in the early 1980s I performed a couple of symphysiotomy operations. My hospital had good facilities for Caesarean, albeit under ether anaesthesia, so the need was small.  A colleague in a less well-staffed hospital nearby, where Caesarean was often impossible, performed the operation more regularly and taught me.

Poet’s Corner at last

December 4, 2016

Philip Larkin

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Tom Courtenay in the tourist bookshop, Edward Fox by the Great West Gate, Grayson Perry chatting in the queue. Too timid to tackle such eminences, I struck up conversation with an unknown. “I’m a Larkin” he said, a cousin once removed, or something like that, come up from Truro for the occasion. His ancestor had been the brother of Sidney Larkin, Philip’s father.

We trooped in and settled among the choir. I found myself next to an Arts Council fellow who’d sat on poetry committees with Larkin. Together we pointed out more celebrities. Melvyn Bragg and Alan Bennett opposite. Anthony Thwaite and Alan Johnson over there.

Choral evensong celebrated the 50th anniversary of Barbados’s independence. The ambassador read the lesson, and the choir sang unaccompanied; no congregational singing for once. Psalm 78 had God repeatedly saving the ungrateful Israelites from their folly, finally knocking them into shape, picking David as ruler, and letting them live in peace and tranquillity ever after. I couldn’t see much of a link with either Barbados or Larkin; perhaps it was just psalm of the day.

After the Barbadians and the public had been ushered out, the Larkin crowd moved to the south transept for the dedication. Virginia Bottomley read Solar, The Trees, and Water, Grayson Perry read from Larkin’s 23rd October 1962 letter to Monica about harvest thanksgiving, Blake Morrison gave the address (click here), Anthony Thwaite read the final verse from Church Going. Sir Tom Courtenay read Days, and Reference Back; a real actor showing the amateurs how it should be done. Someone played a recording of King Oliver’s Riverside Blues, a few prayers and it was over.

The Philip Larkin Society (click here) have been pushing this for years. Hull being City of Culture for 2017 helped. So, while Will Gompertz and the BBC filmed a piece for Newsnight, the rest of us milled about, and listened to a few more words from Professor Edwin Dawes, chair of the Philip Larkin Society, and Rosie Millard from the City of Culture. I chatted to a GP from Kent who was chair of the Thomas Hardy Society – the two societies have recently organised some joint events, and of course Larkin was a great admirer of Hardy. I fear I upset one archivist by foolishly saying I thought Larkin’s archive was in Oxford; he put me right that the Bodleian have only a few letters. But I hope I cheered up another, by getting appropriately excited when he told me he had Larkin’s lawnmower in his collection.

Here is that poem. With those wonderful, terrible, unconsoling lines, “The mower stalled twice,” … “I’d even fed it, once.” … “we should be kind/While there is still time.” Yes, he’s deservedly in Poet’s Corner.

The Mower

The mower stalled, twice; kneeling, I found
A hedgehog jammed up against the blades,
Killed. It had been in the long grass.

I had seen it before, and even fed it, once.
Now I had mauled its unobtrusive world
Unmendably. Burial was no help:

Next morning I got up and it did not.
The first day after a death, the new absence
Is always the same; we should be careful

Of each other, we should be kind
While there is still time.

Den Gyldene Freden

November 16, 2016

Getting to be a regular. Previous visit here.

This book about the Swedish painter Anders Zorn’s American travels was on the bar.

zorn-in-us

Zorn got rich in America; he painted three American Presidents, Cleveland, Taft and Teddy Roosevelt. Back in Stockholm he was a leading member of the Bellman club, who drank, dined and sang the troubadour’s songs here. Sometime after 1910 the building fell into disrepair and Zorn bought it for the then huge sum of SEK150K and set about restoration and refurbishment. Despite a few later licks of paint it remains much as he left it.

Zorn died in 1920 leaving the freehold to the Swedish Academy, who still dine weekly in an upstairs room. The waitress says they’re discreet; she learned of Bob Dylan’s literature prize at the same time as the rest of us.

Here’s their private dining room. Each member has their own schnapps glass.

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The other dining areas are a rabbit warren.

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Some pictures and plaques

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Below them all, the kitchen.

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Jim Thornton

Brief Encounter

November 14, 2016

Meeting Point by Louis MacNeice

brief-encounter

Written in the early 1930s, this poem has reminded every reader since 1945, of Celia Johnson and Trevor Howard’s Brief Encounter. David Lean’s film of their unrequited love story turned Carnforth station waiting room into a place of pilgrimage. The poem captures the moment when, for lovers, time stands still. My favourite line, apart from the final couplet, is the intentionally childish, And they were neither up nor down, from the Grand Old Duke of York nursery rhyme. Private passion, all over the place – in public.

Meeting point

Time was away and somewhere else,
There were two glasses and two chairs
And two people with the one pulse
(Somebody stopped the moving stairs)
Time was away and somewhere else.

And they were neither up nor down;
The stream’s music did not stop
Flowing through heather, limpid brown,
Although they sat in a coffee shop
And they were neither up nor down.

The bell was silent in the air
Holding its inverted poise –
Between the clang and clang a flower,
A brazen calyx of no noise:
The bell was silent in the air.

The camels crossed the miles of sand
That stretched around the cups and plates;
The desert was their own, they planned
To portion out the stars and dates:
The camels crossed the miles of sand.

Time was away and somewhere else.
The waiter did not come, the clock
Forgot them and the radio waltz
Came out like water from a rock:
Time was away and somewhere else.

Her fingers flicked away the ash
That bloomed again in tropic trees:
Not caring if the markets crash
When they had forests such as these,
Her fingers flicked away the ash.

God or whatever means the Good
Be praised that time can stop like this,
That what the heart has understood
Can verify in the body’s peace
God or whatever means the Good.

Time was away and she was here
And life no longer what it was,
The bell was silent in the air
And all the room one glow because
Time was away and she was here.

By Louis MacNeice

#WorldWithoutDowns

October 9, 2016

Eugenic NHS screening should stop

sally-and-olly

Sally Philips’ powerful BBC documentary, A World Without Down’s Syndrome? (iPlayer here, articles here or here), deploring how NHS screening may soon eradicate the syndrome, has provoked a pro-choice push back (e.g. here, here, here and here).

Philips’ son Olly has Down’s syndrome. He lives a worthwhile life, enhances the lives of those he meets, and has taught her that many parents are given unduly pessimistic information about prognosis.

Her opponents accuse her of bias in the other direction. They say that Olly is a relatively high functioning boy with Down’s and that Philips, a successful actress, ignores the reality of caring for a more typical children in less privileged circumstances. They also suspect that Philips, who is quite open about her Christian faith, is secretly anti-choice, and wants to impose her rose-tinted view on others.

I’m pro-choice – I actually perform abortions – but I’m on Philips’ side on this one. She understands that people make different choices, and as a good liberal accepts that. Her objection is to deploying the power of the state to screen for a particular vulnerable group, those with Down’s, for which the only “treatment” is abortion. She’s asking us to consider how members of other similar groups would feel if that power were directed to screening for people like them.  She’s accusing the NHS Down’s screening programme of eugenics.

It’s a serious accusation. My NHS Down’s screening colleagues would be mortified to be so accused. Ever since Hitler incorporated eugenic ideas in his mad schemes for racial purification, eugenics has been a dirty word.  NHS screeners say they’re nothing like that: “We’re just offering choice. No-one has to have the test. If they have the test and find out the baby has Down’s, no-one is forced to abort. The counselling is carefully non directive.”

But the programme overall is clearly encouraging Down’s abortion. The government has decided that Down’s screening is worthwhile because most parents choose abortion. If no-one did so, screening would simply add six months of futile worry to 600 or so parents’ lives. Someone has judged that the “benefits” of preventing the births of 600 Down’s babies outweigh the costs of the screening tests and abortions. That’s a perfectly reasonable decision for a parent to make – parents may decide to abort a pregnancy with lesser abnormalities than Down’s, about 180,000 abort normal pregnancies – but it’s not a decision for the state.

To see why, consider some hypothetical, and some not so hypothetical, prenatal tests. Say for skin colour, sexual orientation, autism, bipolar disorder, increased cancer risk.

Imagine a woman who chooses to abort a healthy child because his skin is black. Perhaps she knows the father was black and she prefers a white child. We may not approve, but unless we are prepared to argue that women don’t have the right to choose, we would support her decision. But we would never, I hope, offer NHS skin colour testing because we wanted to give parents the right to choose the skin colour of their offspring.

Perhaps that’s a far fetched example. Consider parents who choose abortions for sexual orientation, autism, bipolar disorder, increased cancer risk. Individual parents may one day choose to abort pregnancies for any of these reasons. Tests will soon be available for many more genetic abnormalities, some serious, some trivial and many in between. As individuals we will likely agree with some decisions and be shocked by others. A woman has the right to choose. But the state does not.

Many people think that somehow, by discussion and argument, and fancy cost-benefit analyses, the NHS, i.e. the state, will be able to decide that some abnormalities justify screening and others do not. It won’t. People will never agree. Even two middle class liberals like Sally Philips and I can’t agree whether a diagnosis of Down’s syndrome justifies abortion. Collective prenatal screening decisions will always be arbitrary and discriminatory. They will get progressively more difficult.

Now is the time for the NHS to step back; it has plenty else to worry about. Leave prenatal screening to the private and charitable sectors, i.e. to genuinely individual choice.

Jim Thornton

 

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