19 April 2007

Why do women have late abortions?

An important new study finds that indecision is a major factor in delay. Jennie Bristow reports.

‘Late abortion’ has become the subject of intense media and policy interest over recent years. Whether it is to do with discussions of 4-D ultrasound images of ‘walking’ fetuses, advances in neonatal medicine and ‘fetal viability’, or simply because of the emotive character of the abortion debate today, many commentators raise public concerns about the ethics of allowing women to have abortions at up to 24 weeks’ gestation. At a policy level, the emphasis is on increasing women’s access to abortion services in the first trimester of pregnancy, with the aim that women who have abortions do so early on.

There is much to be said for improving access to abortion in the early stages of pregnancy – above all, that it is a better experience for women. The development of procedures such as Early Medical Abortion (EMA), which is a safe, straightforward and cost-effective procedure for abortion at 63 days’ gestation and under, allow women a greater choice of methods and give abortion providers greater ability to meet demand in the first few weeks. The fact that, since 2003, there has been a relative increase in abortions at gestations of under 10 weeks compared with those that take place later in the first trimester, is welcome.

But whatever the improvements to Britain’s early abortion service, women continue to need access to abortion services later on in pregnancy. It remains the case that ‘late abortions’ – those that occur after 13 weeks of pregnancy - account for approximately 11 percent of all abortions. Furthermore, 1.4 percent of all abortions occur after 20 weeks.

Why do women have late abortions? Despite all the debate about the ethics of abortions after 13 weeks of pregnancy, this question is rarely asked. But a significant new study, conducted by the Centre for Sexual Health Research at the University of Southampton and the School of Social Policy, Sociology and Social Research at the University of Kent, has thrown some much-needed light on this issue.

The study asked 883 women who had had second-trimester abortions what they felt were the reasons for the delay – and found that, as with all women seeking abortion today, their decisions and experiences are based on a range of complicated ‘real life’ factors. Just as the decision to have an abortion is rarely made in ideal circumstances, the timing of a woman’s abortion cannot always be tailored to best practice standards.

No single reason

One key finding from this study is that there is no single reason why women have abortions in the second trimester. Indeed, 13 different reasons were selected by at least one fifth of the respondents*, ranging from delays in confirming the pregnancy to uncertainty about whether to have an abortion to delays in accessing the abortion services: 

  • I was not sure about having the abortion, and it took me a while to make my mind up and ask for one (41%)

  • I didn’t realise I was pregnant earlier because my periods are irregular (38%)

  • I thought the pregnancy was much less advanced than it was when I asked for the abortion (36%)

  • I wasn’t sure what I would do if I were pregnant (32%)

  • I didn’t realise I was pregnant earlier because I was using contraception (31%)

  • I suspected I was pregnant but I didn’t do anything about it until the weeks had gone by (30%)

  • I was worried how my parent(s) would react (26%)

  • I had to wait more than 5 days before I could get a consultation appointment to get the go-ahead for the abortion** (24%)

  • My relationship with my partner broke down/changed (23%)

  • I was worried about what was involved in having an abortion so it took me a while to ask for one (22%)

  • I didn’t realise I was pregnant earlier because I continued having periods (20%)

  • I had to wait more than 7 days between the consultation and the appointment for the abortion** (20%)

  • I had to wait over 48 hours for an appointment at my/a doctor’s surgery to ask for an abortion (20%)

    (*Respondents could give more than one reason. **Adjusted for missed appointments)

    These findings mirror the experience of those who work in abortion services: namely, that every woman is different, and her reasons for seeking abortion – at whatever stage of the pregnancy – are many and varied. The Southampton/Kent study also indicated the extent to which individual women can experience a range of factors that, cumulatively, lead to a delay in having an abortion. For example, they may not realise they are pregnant until relatively late on in the pregnancy – at which point they may struggle for a while with the decision to have an abortion, and then find themselves having to wait for the procedure.

    Delays in decision-making

    Perhaps the most striking finding of this study is the extent to the delay in obtaining an abortion arose, not from factors within the abortion service such as lack of appointments, but from women’s delay in seeking an abortion in the first place. Significantly, half of the women involved in this study were at 13+ weeks’ gestation by the time they first asked for an abortion.

    Why did it take them so long? The Southampton/Kent report discussed five ‘stages of delay’ along the pathway to abortion:

  • Suspicion of pregnancy

    A large proportion of the women took several weeks even to suspect they were pregnant -  half were over seven and a half weeks’ gestation when they first suspected they were pregnant, whilst one quarter were over 11 weeks 2 days’ gestation. Many did not suspect they were pregnant because they had irregular periods, because their periods continued while they were pregnant, or because they were using contraception. This was particularly the case for women who had had abortions at over 18 weeks’ gestation; and half the women who had an abortion at 21+ weeks had reached a gestation of at least 18 weeks 2.5 days prior to taking a pregnancy test.

    Given that contraception does sometimes fail (and most people assume that it won’t), and that continued periods are usually a sign that a woman is not pregnant, it is hardly surprising that a number of women find themselves ‘caught out’ by a pregnancy they were fairly confident would not happen.

  • Taking a pregnancy test

    Around a third of respondents took over two weeks between suspecting they were pregnant and taking a pregnancy test. Forty-five percent of these women suspected they were pregnant but ‘didn’t do anything about it until the weeks had gone by’. Others said they were ‘not sure about what they would do if they were pregnant’, or raised fears about the reactions of their parents and partners.

    Facing up to an unplanned pregnancy involves making one of two tough decisions – to have an abortion, or to raise a child whom you hadn’t intended to have at this point in your life, if at all. While it may seem less than rational to policy-makers that women might delay confirming their pregnancy, thereby narrowing their choices about what to do about it, one can empathise with this reaction in a real life context.

  • Deciding to have an abortion

    Once their pregnancy was confirmed, around half the respondents took one week or less between taking their test and then making the decision to have an abortion. Among those who took over one week, the most commonly-cited reason (by 65 percent of these respondents) was ‘I was not sure about having the abortion, and it took a while to make up my mind and ask for one’. Reasons for this indecision included concerns about what was involved in having an abortion, and difficulties in agreeing a decision with their partner.

    The impact of women’s indecision about having an abortion is a crucial point for policy-makers and service providers to understand. For many women, abortion is not the obvious solution to an unplanned pregnancy, but a difficult decision that can involve worrying about the procedure itself, taking into account the views of one’s partner or parents, a desire to have a baby when the time and conditions are not ‘quite right’, and worries about the rights and wrongs of abortion.

    Women’s abortion decisions are not made in a vacuum, but depend upon broader changes and complications in their lives and relationships. So for example, in the Southampton/Kent study, women whose partners changed their minds about having a baby were more likely to have over one week’s delay in deciding to have an abortion – expressing the turmoil that would have followed this change of heart.

  • First asking for an abortion

    Interestingly, the Southampton/Kent study found that once women have made up their minds to have an abortion, they are quick to act on that decision. For half of the women the time between making the decision and asking for an abortion was two days or less. This indicates that what women need, once they have decided to have an abortion, is the kind of abortion service that will allow them to act on that decision as quickly as possible.

  • Obtaining an abortion

    In this study, a relatively large proportion of respondents (60 percent) perceived a delay between requesting an abortion and having the procedure. Twenty-three percent waited over three weeks - beyond the minimum standard recommended by the Royal College of Obstetricians and Gynaecologists (RCOG). Why?

    Some of the reasons for delay during this stage were clearly service-related. For example, 30 percent of women said that ‘The person I first asked for an abortion took a long time to sort out further appointments for me’, and 24 percent said ‘There were confusions about where I should go to have the abortion.’ This suggests a certain amount of confusion about the provision of abortion on the part of the first health professional approached – which, for 62 percent of the sample overall, was their own GP.

    Another significant reason for delay given by women who had had an abortion at 18+ weeks, as opposed to 13-17 weeks, was: ‘The person I first asked made it hard for me to get further appointments’. As the authors of the Southampton/Kent study note, at this stage of pregnancy, any delay related to the provision of services clearly carries the possibility of turning a second-trimester abortion into a ‘very late’ abortion.

    However, some of the reasons women reported for delays between deciding to have an abortion and obtaining one were not related to service provision, but rather related to the woman’s continuing indecision about the abortion procedure. In particular, women reported fears about what was involved in having an abortion, and/or having second thoughts which led to missed appointments. So having decided to have the abortion, women at this stage may still balk at going through with it.

    This continuing indecision provides a challenge for service providers, particularly when women are already at a relatively advanced stage of pregnancy when they first present for an abortion. While abortion is legal up to 24 weeks, this does not mean that it will always be possible for women to obtain an abortion at this stage, due to constraints of time, space and staff at those clinics that provide a late abortion service. The impact of missed or cancelled appointments for women seeking a late abortion is significant, as every appointment they miss takes them closer to the 24-week ‘time limit’.

    The key point, however, is that it is not the place of the abortion provider or the policy-maker to push women into making her decision before she is ready to do so. However desirable it is that abortions should be ‘early abortions’ rather than ‘lates’, and however challenging it is to provide a service that is flexible enough to take account of women’s fears and indecision, such flexibility is what an abortion service must provide if it is to allow women a genuine choice.

    What should be done about late abortions?

    At a policy level, there is a recognition that Britain needs an abortion service that can cope with abortions in the second trimester. In 2005, the Chief Medical Officer stated that Primary Care Trusts should ensure that services are available for abortions up to 24 weeks’ gestation, and made several recommendations for the late abortion service (abortion at 20-23 completed weeks). It is clear from the findings of the Southampton/Kent study that focusing simply on early abortion is not an option – women need access to an abortion service that can meet their needs beyond the first 12 weeks of pregnancy.

    As the authors of the Southampton/Kent study suggest, the extent to which many delays in seeking abortion are ‘woman-related’ rather than ‘service-related’, to do with delays in suspecting and confirming pregnancy and deciding to have an abortion, means that there is a limit to how much abortion providers can hope to reduce the extent of late abortion through changes to the service. The study’s authors make some broader recommendations to do with education about the signs and symptoms of pregnancy, and working to improve GPs’ understanding of abortion procedures in order to ameliorate some of women’s fears and speed up referral delays, and these recommendations are useful.

    However, perhaps the most important issue to address regarding late abortion is the cultural prejudice about why women have late abortions in the first place. There is so much debate at the current time about the ‘ethics’ of ‘allowing’ women to have abortions beyond 12 weeks / 20 weeks / add-preferred-time-limit-here weeks, as though women take such decisions lightly. Even within the pro-choice movement, there is an attempt to draw a legal distinction between abortions in the first trimester and those that happen later.

    Yet as the Southampton/Kent study clearly shows, when it comes to why women seek abortions and at what stage they do so, there are no such hard-and-fast distinctions. Just as women who ‘choose’ to have abortions in the first trimester would rather not be pregnant in the first place, women do not ‘choose’ to have a late abortion rather than an early one. They end up in these circumstances because of any number of personal factors, and struggle with their decision, sometimes for weeks on end. A progressive abortion service is one that respects this decision-making process, and gives women the ability to act on their decisions as quickly and appropriately as possible.

    Commenting on the study, Ann Furedi, Chief Executive of BPAS, said:

    ‘Some women are putting off coming in to clinics as early as they need to, and going through weeks of terrible, unnecessary worry for simple want of the facts. It is a scandal that in this day and age, the myths about having an abortion remain unchallenged by school teachers and health professionals. Many tend to skirt round the difficult issue of abortion so as not to cause offence, but this poses measurable risks to women’s health. One-third of women in the UK will have an abortion before the age of 45, so we all need to get real about offering this essential health information.

    ‘We frequently see women who did not know enough about their own bodies to recognise the early symptoms of pregnancy, especially if they have irregular or continuing periods, as many women do. Even where women consult their GP, we know that many family doctors are not up to date with modern abortion techniques and give women unclear advice.

    ‘It’s completely normal to need plenty of time to think about having an abortion. This is true at whatever stage a woman discovers her pregnancy. But some women don’t have time on their side, so we need remove as many of the other delaying factors as we can. A proper government pregnancy and abortion education campaign would be a big help. Every sexually-active woman needs to know about pregnancy symptoms, how to get impartial counselling and where to find maternity or abortion healthcare services. For most women, having an abortion will be medically less risky than having a baby- but very few of the women we see already know that.’

    A summary of the report Second-Trimester Abortions in England and Wales, by Roger Ingham, Ellie Lee, Steve Clements and Nicole Stone, is available to download here.

    This study was related to an earlier report, Influences on young women’s decisions about abortion or motherhood, by the same research team published in 2004. The key findings are available on the Joseph Rowntree Foundation website.

    Read on:

    Late abortions reasons revealed, BBC News, 19 April 2007

    Half of late abortions are for women who didn’t notice they were pregnant, The Times (London), 19 April 2007

    Many women late to recognise pregnancy, abortion study finds, Guardian, 19 April 2007

    Late Abortions – will a shortage of abortion doctors create a crisis?, Woman’s Hour, Radio Four, 20 April 2007