12 June 2008

Q&A: Late abortion

BPAS’ Medical Director Patricia Lohr examines developments and discussions in abortion provision.

Q) What is meant by a ‘late abortion’?

Late abortion is an ambiguous term but generally refers to abortions performed in the latter part of the second trimester of pregnancy. Some authors have described ‘early’ second-trimester abortion procedures as those performed from 13-15 weeks’ gestation, ‘mid’ at 16-19 weeks’ gestation, and ‘late’ as 20-27 weeks’ gestation, with ‘late-term’ reserved for abortions during the third trimester, defined as 27 weeks’ gestation or greater. (1) Others have used ‘late abortion’ to refer to terminations at 21 weeks’ gestation or greater. (2)

Q) What is the law governing late abortion in Britain?

Abortion is legal up to 24 weeks’ gestation when two doctors determine that the risk to a woman’s physical or mental health or the risk to her child(ren)’s physical or mental health would be greater if she continues the pregnancy than if she has an abortion. There is no gestational age limit where two doctors agree that a woman’s health or life is gravely threatened by continuing the pregnancy or where there is substantial risk of a child being born with severe physical or mental abnormalities. In the event that an abortion must be performed emergently, a second doctor’s agreement is not required. (3, 4)

The regulations governing abortion in the United Kingdom (the Abortion Act of 1967 as amended by the Human Fertilisation and Embryology Act of 1990) do not apply in Northern Ireland, however, where abortion is only allowed in exceptional circumstances, such as when the woman’s life is in danger if the pregnancy is continued.

Q) What proportion of abortions in Britain is carried out a) after 13 weeks; b) after 20 weeks; c) after 24 weeks?

Second trimester abortions constitute a relatively small proportion of the total number of abortions in England and Wales. In 2006, the latest year for which statistics are available, 9% of abortions among residents were performed between 13-19 weeks’ gestation, 1.5% from 20-23 weeks, and 0.07% after 24 weeks. (5)

There are no official abortion statistics generated from Northern Ireland. However, for women travelling from Northern Ireland to England and Wales for an abortion, 12% of were performed between 13-19 weeks’ gestation and 2% were 20 weeks or greater.

Q) What is BPAS’ role in providing late abortions?

BPAS provides both medical and surgical abortions to 24 weeks’ gestation. There are few providers of abortion services in Britain who offer terminations to the gestational age limit allowable by law; thus we view this is an important aspect of our service provision.

Q) What procedures are used in late abortions in Britain?

Abortions in the second trimester may be performed with medications that induce labour or by surgical evacuation of the uterus. (6) The most common medical method employed in Britain involves a combination of mifepristone and misoprostol. Dilatation and evacuation (D&E) is the surgical procedure of choice. A D&E involves removal of the fetus and placenta through an artificially dilated cervix using a combination of forceps and vacuum aspiration.

Q) Is feticide routinely performed in late abortions?

Feticide is recommended by the Royal College of Obstetricians and Gynaecologists for medical abortion at 22 weeks’ gestation or greater to avoid the possibility of a live birth. (7) Feticide is also used before D&E by some surgeons, though the true incidence of use is not known. (8)

The gestational age at which feticide is employed before D&E differs among practitioners, but it is typically reserved for terminations above 18 weeks’ gestation. The softening of bone that occurs after fetal demise is proposed to reduce the amount of cervical dilation necessary and to make the procedure easier and faster, thus reducing the risk of complications.

Data supporting the effect of fetal demise on the safety and efficiency of D&E are limited. One randomised-controlled trial showed no difference between feticide with intra-amniotic digoxin and placebo with regard to complication rates or procedure duration when administered prior to D&E at 20-24 weeks gestation. (9) Women in this study did, however, report a preference for fetal demise prior to the abortion.

Q) What, in your view, would be the best practice approach to offering a late abortion service?

Despite a general downward shift in the gestational age at which abortion is performed in the first trimester, the small proportion of women obtaining abortions in the second trimester has remained stable over time. (10) Contributing factors include late diagnosis of pregnancy or of fetal anomalies, logistic and financial barriers to abortion services, and the time that some women need to decide whether or not to have an abortion. (10, 11) This suggests that there are educational, counselling and policy measures that need to be enhanced, but that the retention of access to second trimester abortions will continue to be essential for some women.

Debate still exists as to whether surgical or medical abortion is optimal for second trimester pregnancy termination, and little is known about women’s preferences. The current evidence appears to favour D&E over mifepristone and misoprostol in terms of safety and efficiency, but large randomised trials are needed before definitive conclusions can be made. (12, 13) An additional challenge to the provision of second trimester surgical abortion is the availability is a large pool of skilled surgeons. Specialised training and the maintenance of an adequate caseload are required to perform D&E safely; yet training opportunities are often limited. (7, 14, 15)

The best practice approach would be a woman-centred one, where a range of services is offered by skilled and competent providers and is easy to access. This requires an understanding that provision of second trimester abortions is important, that adequate training is available, and a commitment to the maintenance or, in some cases, enhancement, of clear and well-funded pathways to services.

References

1) Gans Epner JE, Jonas HS, Seckinger DL. Late-term abortion. JAMA. 1998;280:724-9.
2) Grimes DA. The continuing need for late abortions. JAMA. 1998;280(8):747-50.
3) Human Fertilisation and Embryology Act 1990. London: HMSO; 1990.
4) Abortion Act 1967. London: HMSO; 1967.
5) Department of Health. Abortion Statistics, England and Wales: 2006 [Electronic]. Crown; 2007 [cited 16 April 2007]. Available here.
6) Stubblefield PG, Carr-Ellis S, Borgatta L. Methods for induced abortion. Obstetrics and Gynecology. 2004;104(1):174-85.
7) Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. London: RCOG Press; 2004.
8) Haskell WM, Easterling TR, Lichtenberg ES. Surgical Abortion After the First Trimester. In: Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, editors. A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone; 1999. p. 123-38.
9) Jackson RA, Teplin VL, Drey EA, et al. Digoxin to facilitate late secondtrimester abortion: a randomized, masked, placebo-controlled trial. Obstetrics and Gynecology. 2001;97:471-6.
10) Ingham R, Lee E, Clements S, et al. Second-Trimester Abortions in England and Wales. 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, 2007
11) Drey EA, Foster DG, Jackson RA, et al. Risk factors associated with presenting for abortion in the second trimester. Obstetrics and Gynecology. 2006;107(1):128-35.
12) Grimes DA, Smith SM, Witham AD. Mifepristone and misoprostol versus dilation and evacution for midtrimester abortion: a pilot randomised controlled trial. BJOG. 2004;111:148-53.
13) Autry AM, Hayes EC, Jacobson GF, et al. A comparison of medical induction and dilation and evacuation for second-trimester abortion. American Journal of Obstetrics and Gynecology. 2002
2002/8;187(2):393-7.
14) Eastwood KL, Kacmar JE, Steinauer J, et al. Abortion training in United States obstetrics and gynecology residency programs. Obstetrics and Gynecology. 2006;108(2):303-8.
15) Francome C, Savage WD. Gynaecologists’ abortion practice. BJOG. 1992;99(2):153-7.