Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489

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Best Practice & Research ClinicalObstetrics and Gynaecology

journal homepage: www.elsevier .com/locate /bpobgyn

5

Why do women present late for induced abortion?

Ellie Lee, BSc, PhD, Cert Ed, Senior Lecturer in Social Policy a,*, Roger Ingham,BSc, DPhil, Professor of Health and Community Psychology b,c

a SSPSSR Cornwallis NE, University of Kent, Kent CT2 7N, UKb School of Psychology University of Southampton, Southampton SO17 1BJ, UK

Keywords:abortionsecond trimesterdelay

* Corresponding author. Tel.: þ44 1227 827526;E-mail addresses: E.J.Lee@kent.ac.uk (E. Lee), ri

c Tel.: 023 8059 2587; Fax: 023 8059 4597.

1521-6934/$ – see front matter � 2010 Elsevier Ltdoi:10.1016/j.bpobgyn.2010.02.005

This article summarises the findings of studies relating to whywomen present for abortion at gestations of more than 12 weeks.Its primary focus is on British experience, but relevant studies fromother countries are described. Key findings reveal that there aremany different reasons. Much of the delay occurs prior to womenrequesting an abortion; other key issues include women’s concernsabout what is involved in having the abortion and aspects ofrelationships with their partners and/or parents. Further, afterrequesting an abortion, delays are partly ‘service-related’ – forexample, waiting for appointments – and partly ‘woman-related’for example, missing or cancelling appointments. The relativecontributions to the delay of these various factors are discussed.The implications of the research for abortion education and serviceprovision are considered. Abortion for reasons linked to foetalabnormality is not covered in this article.

� 2010 Elsevier Ltd. All rights reserved.

This article presents the findings of the relatively low number of studies that have considered whywomen present for termination of pregnancy procedures at a gestation of more than 12 weeks. Much ofthe discussion summarises the findings of the largest and most recent British study, which was con-ducted by the authors in 2006 and 2007.1 Previously published work from Britain and relevant studiesfrom other countries are also discussed where appropriate. Finally, we consider the implications of thisresearch for abortion education and service provision. Abortion for reasons relating to foetal abnor-mality is not covered in this article.

The discussion of second trimester abortion needs to be set in the context of its incidence. In GreatBritain, whilst the overall abortion rate has been gradually increasing since the new legal framework

Fax: þ44 1227 827005.@soton.ac.uk (R. Ingham).

d. All rights reserved.

E. Lee, R. Ingham / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489480

took effect in 1968, and especially over the past decade, there have also been changes in the temporalpatterning of the procedures. Table 1 shows that the large majority of procedures are provided in thefirst trimester and, further, that there has been a general shift towards earlier procedures in recentyears.

The overall proportion of abortions carried out under 10 weeks has increased from 56% in 1995 to67% in 2005. However, these developments have been accompanied by only a slight reduction in thedemand for abortions in the second trimester, with the proportions at 13 or more weeks declining from14% in 1985, 11% during 1995–2000 and 10% in 2005.2

Second trimester abortions are less desirable from a public health policy perspective; policy in GreatBritain is that abortion should be provided to women as early as possible. This is predicated on therecognition that procedures performed at early gestations are relatively safer medically than thoseperformed at more advanced gestational stages.3 Other factors also exert influence; for example,financial costs increase with gestation and, while discussion of this area is beyond the scope of thisarticle, the perception that moral objections to abortion are more powerful at later gestations may haveinfluence. During the recent public debate in Britain, those who object to the provision of abortion havemade so-called ‘late abortion’ a major focus of their arguments.4 Early abortion may therefore appear tosome to be less ‘objectionable’. Stressing that the abortion service aims to provide early abortion wherepossible may be attractive to those wishing to avoid confrontation about the ethics of abortion.

Policy on abortion provision has developed in important ways. The Department of Health hasincreasingly ‘mainstreamed’ abortion services as part of the broader framework for provision of sexualand reproductive health services. National disparities in the proportions of abortions funded andprovided by the National Health Service (NHS) have also been recognised as a concern. In addition, policyhas sought to address problems of access to abortion by using the capacity of specialist independentservice providers. The overall proportion of procedures carried out by such agencies has increased from45% to 60% in the past 10 years, with a shift in the proportion of these abortions being carried out undercontract to the NHS from around one-third to three-quarters over the same time period.

Second trimester abortion features in public health policy. Appropriate medical regimens are set outby the Royal College of Obstetricians and Gynaecologists (RCOG) of United Kingdom,5 and these, as wellas the Department of Health, have stated that Primary Care Trusts (PCTs) should have systems in place toensure that ‘no’ woman seeking abortion and meeting relevant legal criteria should have to wait morethan 3 weeks from first referral to abortion procedure.6 The Medical Foundation for AIDS and SexualHealth Services (MedFASH) has stated that commissioners of services and service providers shouldensure that abortion is available locally up to the maximum legal time limit.7 The Social Exclusion Unit’sreport on teenage pregnancy noted the relatively higher proportion of abortions amongst teenagers thatoccur during the second trimester than is the case for women over 20 years of age.8

The provision of abortion in the late second trimester, specifically, has become a policy concern. Inresponse to the media debate about ‘late abortion’, the Chief Medical Officer (CMO) stated in 2005 thatwomen are legally entitled to seek abortion on the basis of the terms of the law, under which abortioncan be provided up to 24 weeks gestation, and that PCTs should ensure that services are available. TheCMO made a number of important recommendations for the late abortion service (abortion at 20–23completed weeks) which covered, amongst other issues, the development of a best practice protocol,commissioning of a review, staff training needs and improved identification of sources of delay.9 At the

Table 1Overall abortion rates and percentages (rounded) of abortions by gestation length, 1985–2005.

Year Overall ratesa Percentages gestation length (in weeks)b

<10 10–12 13–19 20 þ

1985 12.5 – – 12 21990 15.5 – – 11 11995 14.5 56 34 10 12000 17.0 58 30 10 12005 17.8 67 23 9 1

a age-standardised rates per 1000 women aged between 15 and 44.b data for some gestation lengths prior to 1995 are not available due to a change in the way data were presented.

E. Lee, R. Ingham / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489 481

time of writing in Summer 2009, the Department of Health has indicated that the CMO’s recom-mendations will be included in good practice commissioning guidance for contraception and abortionservices, and that streamlining of referral for late abortion (as yet undefined) will be pursued byestablishing a central telephone booking service.

Attention has also been paid to encourage innovation in regard to increasing the proportion of earlymedical abortions (EMAs). Policy emphasises the importance of women accessing abortion at 9 weeks’gestation or earlier whenever possible, because they can then have the choice of medical or surgicalabortion, with the former avoiding the need for anaesthesia and surgical intervention. Data presen-tation changed in the mid-1990s but, in 1995, 10% of under 9-week abortions used EMA (this repre-sented 4% of all abortions), in 2002, 18% used EMA (10% of all abortions) and, in 2005, 30% used EMA(20% of all abortions).2 PCTs defined by the Healthcare Commission as providing a ‘good’ service arethose where 70% of abortions are performed by 9 completed weeks’ gestation.10 In 2005–06, fundingwas allocated to assist PCTs to increase the proportion of EMAs.11

In sum, although policy enables abortion to be provided throughout the second trimester, emphasis isplaced on taking measures to increase the proportion of abortions that occur at earlier stages of gestation.In this light, questions to consider are why do women present for abortion in the second trimester? Also,what, if anything, can be done to reduce the proportion of abortions provided after 12 weeks? In theremainder of this article, we outline some of the answers that research has provided to these questions.

British research findings prior to 2006

One of the issues that has been explored in the limited research hitherto is the extent to whichdelays created by services explain late procedures. One view is that some women present at an earlypoint in gestation, but are delayed either at the point of referral or because the procedure is notprovided soon enough after referral. Finnie et al. found that, for women attending hospital abortionclinics in the South Durham area, 44% were treated within 3 weeks from the point of referral, pointingto a large disparity with national standards.12 A survey of all English PCTs by the All Party ParliamentaryPro Choice Group found that more than one-quarter had waiting times of more than 3 weeks.13

Access to second trimester abortion procedures has also been considered. The attitudes of NHSgynaecologists practising in Britain to providing abortion procedures at later gestations were assessed byFrancome and Savage in a now somewhat dated study. They found that 89% stated their own personalupper limit for performing abortions was 20 weeks, although there was ‘considerable theoreticalsupport for later abortions’, suggesting ‘there is a disparity between the fact that many were unwilling toperform an abortion after 20 weeks, except for malformation (of the foetus) or to save a woman’s life, andyet would support the legal availability of later abortions for wider implications if someone else werewilling to perform them’.14, p154 Roe et al. considered attitudes and training of trainee doctors working asobstetrician–gynaecologists in the NHS. Whilst large majorities said they were prepared to do somework associated with abortion (e.g., assess or clerk patients), 28% of junior doctors reported beingunwilling to perform first trimester abortions and 38% as being unwilling to perform second trimesterprocedures (although 88% said they would participate in abortion for foetal abnormality).15

More recently, a study of under-18 pregnancies ending in abortion included a survey that collectedthe perceptions of, and information from, service commissioners, NHS hospital consultants inobstetrics and gynaecology and teenage pregnancy co-ordinators. The quality of the abortion servicewas generally perceived as being notably poorer at later gestational stages in almost all areas. Therewas a commonly reported problem of poor access to abortion after the first trimester. Despite the legalupper time limit of abortion of 23 completed weeks, the highest reported cut-off point was, in practice,20 weeks. In most sites, it was reported that abortions are not provided in NHS hospitals from an earlierstage – between 13 and 16 weeks in most cases. Comments made by respondents indicated that,commonly, a ‘division of labour’ existed between NHS providers and the independent sector with thelatter providing later terminations, albeit often funded by the NHS. It was noted that this often requiredwomen to travel some distance to access the procedure. In some sites, it also appeared that NHS unitsdid not provide these procedures because of dislike amongst staff of involvement with abortionprovision.16 These findings help to explain the very marked shift in provision from the NHS to theindependent sector in recent years.2

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Other research, however, challenges the view that late procedures are ‘primarily’ a result of servicefactors (and thus amenable to improvement through better access). The relative contribution to lateprocedures of service-related delays, and delays for other reasons, was considered in a study by Georgeand Randall published in the mid-1990s. It found that only 13% of second trimester abortions couldhave been managed earlier by service improvements, since most women requesting later abortions didnot ‘seek’ abortion until a relatively late gestational stage. The study reported on findings of a retro-spective analysis of records of all 111 women who had an appointment during the first year of a secondtrimester Unplanned Pregnancy Counselling Clinic (UPCC). The reasons women gave for late presen-tation were grouped into ‘unpreventable’ or ‘preventable’. Ninety women received counselling, ofwhom 71 had reasons recorded for late presentation. Twelve potentially preventable late presentationswere found. Unpreventable reasons for late presentations for abortion were varied, and includedconcealed teenage pregnancies, peri-menopausal women or women with irregular menstrual cycleswho did not associate amenorrhoea with pregnancy, as well as pregnancies that had been initiallywanted.17

More recently, abortion at 19–24 weeks gestation was investigated through a study of clientsattending Marie Stopes International (MSI) clinics. Twenty-six women were interviewed face to faceand 84 completed questionnaires. Although service factors emerged as part of the explanation for latepresentation, it was found that for ‘most’ women ‘a combination of factors’ led to late abortion. Theseincluded significant delays in accessing services, failure to realise they were pregnant until relativelylate, not recognising the ‘signs and symptoms’ of pregnancy until ‘an advanced stage’ and, for a smallnumber who were aware they were pregnant at an early stage, denial. A few reported a change in theirlife circumstances since becoming pregnant.18

In the light of the policy context, administrative data and insights of the limited research discussedabove, a recent study by the present authors sought to find out more about the reasons for the inci-dence of second trimester abortion in England and Wales. The key results are summarised.

Second trimester abortions in England and Wales

The key concepts used in this study were ‘pathway to abortion’ and ‘delay’. Five stages on thepathway to abortion were identified, and the study sought to find out about experiences of delay atthese stages. These stages were

1. time to suspecting pregnancy;2. time between suspecting and taking test;3. time between test result and decision;4. time between decision and requesting abortion; and5. time between requesting abortion and procedure.

The methodology was a self-completion questionnaire, with a range of options – including 39specific potential reasons for delay – from which respondents could select those that they felt hadapplied. The options were generated from a combination of close reading of the literature discussedabove and pilot work involving detailed interviews with staff working for abortion providers. Ques-tions also included space for further open comments by respondents.

The sample was 883 women recruited at eight British Pregnancy Advisory Service (BPAS) clinics andtwo additional independent sector clinics. The selected clinics carried out around 41% of the almost 20000 second trimester abortions to England and Wales residents in 2005. The sample composition wascompared against national data and, where necessary, data were weighted to take any disparities intoaccount. The main findings were as follows (Table 2).

General reasons for second trimester abortion

Despite our own data being concerned with abortions occurring at 13 or more weeks’ gestation, theresults closely mirrored those obtained in the smaller MSI study (mentioned above) on much later

Table 2Specific reasons reported for delays over whole sample (n ¼ 858).

Reason Percentage

I was not sure about having the abortion, and it took me a while to make my mind up and ask for one 41I didn’t realise I was pregnant earlier because my periods are irregular 38I thought the pregnancy was much less advanced than it was when I asked for the abortion 36I wasn’t sure what I would do if I were pregnant 32I didn’t realise I was pregnant earlier because I was using contraception 31I suspected I was pregnant but I didn’t do anything about it until the weeks had gone by 30I was worried how my parent(s) would react 26I had to wait more than 5 days before I could get a consultation appointment to get the go-ahead for

the abortiona24

My relationship with my partner broke down/changed 23I was worried about what was involved in having an abortion so it took me a while to ask for one 22I didn’t realise I was pregnant earlier because I continued having periods 20I had to wait more than 7 days between the consultation and the appointment for the abortiona 20I 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.a Adjusted for missed appointments.

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procedures. Multiple factors explained late procedures, with the vast majority (85%) reporting morethan one reason for delay.

The five stages of the pathway and associated delays

The specific reasons reported were categorised into five stages in the pathway as noted previously. Theproportions of women who reported at least one reason for delay during each of these five stages were

x suspecting pregnancy (71%);x between suspecting and confirming pregnancy with a test (64%);x between confirmation of result and deciding to have an abortion (79%);x between deciding and first asking for an abortion (28%); andx between asking and obtaining an abortion (60%).

In terms of time, women’s reports indicated that much of the delay occurred ‘prior to’ requesting anabortion. Fifty percent of the women were at 13 or more weeks’ gestation by the time they ‘first asked’for an abortion.

Delay in suspecting pregnancy

Of the overall sample, 71% of respondents reported at least one reason for delay within this cate-gory; lack of early awareness of pregnancy is thus an important factor. Half of the sample were at over52 days’ gestation when they first suspected they were pregnant, with one-quarter being over 79 days’gestation. The most common factors reported by those who were above this group’s median gestation(52 days) at suspecting pregnancy were

x because my periods are irregular (49%);x because I continued having periods (42%); and/orx because I was using contraception (29%).

Delay in taking pregnancy test

Sixty-four percent of respondents overall selected at least one reason for delay between suspectingpregnancy and confirming it with a test. The median reported time between suspecting and taking

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a test was 14 days, with the most commonly reported reason for this (reported by 45% of women) beingthat, while they suspected they were pregnant, they ‘did not do anything about it until the weeks hadgone by’. Other responses reported by fairly large minorities were that they were ‘not sure about whatthey would do if they were pregnant’ and/or fears over the reaction of their parents and/or partners.

Seventy-one percent of women confirmed their pregnancy at home; these women were less likelyto wait over 14 days to do this – as opposed to those who were tested at a doctor’s surgery or clinic. Partof the delay amongst some of the latter group was due to their not wanting to see their regular doctorand having to spend time finding somewhere else to go for a pregnancy test.

Delay in deciding to have abortion

Seventy-nine percent of respondents reported a delay in deciding to have an abortion, with aroundhalf the respondents taking 1 week or more between their test result and the decision to have anabortion. Among respondents who took over the median time of 1 week, the reasons cited by morethan 10% of them are shown in Table 3.

These data suggest that, in addition to some general indecision, responses of partners form animportant part of the context for decision making for some women. The choice to terminate a preg-nancy, and the difficulties some experience making that choice, can be bound up with women’srelationships.

Delay in first asking for abortion

One area where reported delays were noticeably short was in the time between women deciding tohave an abortion and first asking for one. For 50% of the women, the time between making the decisionand asking for an abortion was 2 days or less. Of those who took 4 days, some reported ‘I had to waitover 48 h for an appointment at my/a doctor’s surgery to ask for an abortion’ whilst others reportedthat ‘I did not want to see my regular doctor to request an abortion, and it took time for me to findanother doctor’. In general, findings in this area appear to confirm the evidence from elsewhere thatabortion decision making for many women typically takes place outside of the influence of medicalprofessionals.19

Delay in obtaining abortion

A relatively large proportion of the sample (60%) reported one or more reasons for delay betweenrequesting an abortion and having the procedure. Forty-two percent of the total sample waited over 2weeks between requesting and obtaining an abortion, whilst 23% waited over 3 weeks – beyond theminimum time period recommended by the RCOG. The major reasons (reported by 15% or more ofthese women) are shown in Table 4.

These data show that reasons for delay at this stage are not just service-related. For a few, delay isa product of continuing indecision – for example, having second thoughts – which led to missedappointments. For others, it can be seen that delay was indeed caused by service-related factors, bothdelays at the referral stage as well as delays in obtaining appointments with the abortion provider afterreferral. There appeared to be a certain amount of confusion about the local care pathways for abortionprovision on the part of the first health professional approached; for 62% of our sample overall, this wastheir own general practitioner.

Women aged under 18

In some public debate about abortion, it has been claimed that younger women are more likely toseek later abortions because of various factors, including denial of pregnancy. Our analyses thereforeconsidered differences in the sample by age. Notably, variations were not substantial; the mediangestation was only 1 week longer for women under 18 years old than over 18. There were, however,some statistically significant differences in the reported reasons for delay according to age. For

Table 3Reason for delay in deciding to have an abortion (n ¼ 349).

Reported reasons Per cent

I was not sure about having the abortion, and it took me a while to make my mind up and ask for one 65My relationship with my partner broke down 30I thought the pregnancy was much less advanced than it was when I asked for the abortion 29I was worried about what was involved in having an abortion so it took me a while to ask for one 27I was hoping/waiting to see if my partner would support me in having a baby 20My partner changed his mind about having a baby 11

Reasons cited by >10%.

E. Lee, R. Ingham / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489 485

example, women under the age of 18 were more likely than women over 18 to report delays at the earlystages of the decision-making process for the following reasons:

x having a suspicion of pregnancy but not doing anything about it;x not being sure what they would do if they were pregnant (leading to a delay in taking a pregnancy

test); andx concern about what an abortion involved, so waiting to ask for one.

Women under 18 were also more likely to report delays because of concerns about how theirparents would react. Like older women, however, indecision associated with partners’ reactions wasalso reported, which confirms findings of previous research about young women who opt forabortion.16

Later second trimester abortions

Analyses were conducted to compare women in the sample who terminated pregnancies at 18 ormore weeks with those who did so at 13–17 weeks. The main finding was that abortions at 18 or moreweeks are strongly associated with delays in the earlier stages of the abortion pathway. Women who hadabortions at 18 or more weeks took longer to suspect that they were pregnant and to confirm thepregnancy with a test. Women who had an abortion at 18 or more weeks were also more likely to reporthaving experienced continuing ‘periods’, which delayed the suspicion that they were pregnant, and that‘the person I first asked made it hard for me to get further appointments’. At this stage of pregnancy, anydelay clearly carries the possibility of turning a second trimester abortion into a ‘very late’ abortion.

Studies from other countries

Late presentation for abortion has also attracted attention from researchers in the USA. The contextfor the interest is similar to Britain in that there has been a general shift of timing of abortion to earliergestation but a stasis in the proportion in the second trimester. Finer et al. thus note that due toimproved access to EMA and improved techniques for early surgical abortion, ‘‘the proportion of

Table 4Reasons for delay in obtaining abortion (n ¼ 186).

Reasons provided (service related) Percent

I had to wait more than 5 days before I could get a consultation appointment to get the go-ahead forthe abortiona

32

The person I first asked for an abortion took a long time to sort out further appointments for me 30I had to wait more than 7 days between the consultation and the appointment for the abortion* 27There were confusions about where I should go to have the abortion 24Reasons provided (personal related)I was having second thoughts about having the abortion I had asked for, so I missed/cancelled some

appointments and then re-booked them16

Reasons cited by >15%a Percentages add to more than 100 since multiple responses were permitted.

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abortions that were performed in the first 8 weeks’ gestation increased from 52% to 59% between 1991and 2001. Even so, about 11% of abortions took place at 13 weeks gestation or later in 2001.’’20 The legaland policy context, however, is different from that in Britain. Some states have particular legalrestrictions on access. The availability of abortion is affected by a lack of providers in some states,meaning that women have to travel to obtain procedures, and abortion is not routinely funded by thestate. Researchers have thus been concerned to discover if these service factors delay access.

Bitler and Zavodny used state-level data from 1974 to 1997 to consider whether funding restrictions,parental involvement laws and laws mandating waiting periods between consultation and procedureaffected the timing of abortions. It was found that laws for minors and enforced waiting periods werepositively correlated with the proportion of second trimester abortions. The former, however, had thiseffect by lowering the first trimester abortion rate rather than by delaying abortions. Fundingrestrictions were not found to have an effect.21

Other studies have adopted a similar approach to that of Ingham et al., looking at what factors createdelay in stages leading to abortion. Drey et al. compared women aborting in the first and secondtrimesters. They found a ‘myriad’ of factors implicated in delay. Service factors did emerge as impor-tant, since second-trimester patients reported being referred by other clinics, finding it difficult to finda provider, living further from a clinic than did first trimester patients and struggling to obtain funding.While women aborting in the first trimester reported shorter delay at all steps leading to abortion, thedifference in timing was greatest in the step to suspecting pregnancy. A lack of recognition of thepregnancy due to relative absence of signs compared to first trimester patients as well as a lack ofclarity about when they last had a menstrual period were important.22

Foster et al. also found that many factors can cause delay, including absence of pregnancy symp-toms, obesity, fear of abortion, denial of the pregnancy, difficulty getting funding for abortion, difficultydeciding, having had a prior second trimester abortion and an unsupportive partner. These authorsemphasise that ‘‘interventions which are aimed at improving women’s ability to identify a pregnancyat an earlier gestation could be helpful.’’ 23, p291 Finer et al. also compared first and second trimesterpatients and their findings were broadly similar. Delay at each stage was longer for the latter group,with delay in suspecting a pregnancy being important. This study detected additional evidence thatfinancial factors cause delay. Statistically significant differences between the two groups whichaccounted for delay included it taking a long time to make arrangements, in particular raising moneyfor the abortion, and worries about the cost of abortion.20 These financial factors, among others, arealso noted by Kiley et al. from their comparison of first and second trimester patients. Increased odds ofsecond trimester abortion were associated with problems obtaining money, and finding a provider. Notusing contraception was reported similarly by both groups.24

Studies have also been reported on data from Singapore and Vietnam. Key findings of the latterstudy concur strikingly with those obtained in Britain and the USA. The study conducted in Vietnamfound that ‘‘three broad categories for factors influencing delays in obtaining abortions emerged: mostwomen failed to recognize their pregnancy during the first trimester; women described structuralbarriers to accessing services earlier; and some women either needed time to make a decision or onlydecided to abort after other events transpired.’’25, p1812 The Singh et al. study in Singapore consideredthe profile of women presenting for abortions at the national University Hospital. Almost 90% of thewomen in the study underwent first trimester abortion. Of those aborting in the second trimester, theproportion of women aged under 20 was statistically significantly higher.26

In 2008, a set of articles about second trimester abortion covering international experience, whichincluded an article about the British study discussed above, were published in the journal ReproductiveHealth Matters (countries discussed include the Netherlands, Vietnam, Nepal, South Africa, India, theUSA and Mozambique).27 There is not enough space here to do justice to the content of these articles,but a point that emerges is that, even where early abortion is highly accessible, women still terminatein the second trimester. Thus, in the Netherlands where abortion is highly accessible, in 2006, over 6%of abortions occurred in the second trimester. While service-related factors did not feature much, manyof the other reasons reported by Dutch women for delay were remarkably similar to those identified forBritish women. The most frequently reported reason was that of women not realising they werepregnant because of continued bleeding or regular contraceptive use were. Ambivalence aboutwhether to end or continue pregnancy was reported by just under one-third.28

E. Lee, R. Ingham / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489 487

To summarise, key findings of British research about second trimester abortion are

- There is no single, dominant reason why women have abortions in the second trimester;- Much of the delay occurs prior to women requesting an abortion, and is caused by lack of

recognition of pregnancy;- Women presenting late are frequently ambivalent about whether to have an abortion;- Relationships with partners and/or parents play a role in delays in women’s decision making;- Women’s concerns about what is involved in having an abortion create delay; and- After requesting an abortion, delays are partly service-related, to do with waiting for appoint-

ments, and partly ‘woman-related’, to do with missing or cancelling appointments.

Comparing the British experience with elsewhere, most variation seems to be in the extent to whichservice-related factors create delays. Studies of the USA, with its markedly different fundingarrangements, emphasise the importance of these factors, in particular, lack of funding. Evidence fromthe Netherlands appears to suggest that where abortion is highly accessible, the proportion of secondtrimester abortions is, to some extent, lower than elsewhere, but still not insubstantial. For Britain, themost pressing area for service improvement emerges as ‘education of those who refer women forabortion about local second trimester services’. Given the evidence of some confusion regardingabortion provision amongst referrers (most usually a general practitioner (GP)), local referral pathwaysshould be made clearer to all health professionals who may be involved. It is also important thatwomen can see referrers who will not make it difficult for them to get further appointments.

Since many women reported ‘worry’ about having an abortion, another area to consider is ‘educationof referrers about how best to discuss with women the safety of abortion and how abortion works’.

Given that many British women who have second trimester abortions do not present until after 12weeks, improvements to referral pathways may not significantly reduce the proportion of abortionsprovided in the second trimester. However, they may impact on the relative distribution of abortionswithin weeks 13–24, most importantly leading to a reduction in procedures occurring late in thesecond trimester.

One noteworthy finding comparing international research is that very similar issues are raised indifferent countries. The finding that common causes of delay are women not suspecting they are pregnantand ambivalence about the resolution of the pregnancy is striking. These ‘woman-related’ causes of delayare reported seemingly regardless of variation in the national abortion policies and practices.

It is difficult to see how these reasons for delay can be directly addressed so as to enable women topresent earlier in pregnancy. Education about the signs and symptoms of pregnancy might be pursued.This would entail promoting a greater awareness of symptoms including the fact that some women doexperience continuing bleeding while pregnant. Encouraging women’s involvement in abortionservices ‘pre-decision’ might also be beneficial. Promoting the understanding that seeking help from anabortion service does not imply a definite decision to have an abortion could help to speed up theprocess between finally asking for an abortion and obtaining one.

However, an inescapable conclusion is that it is unrealistic to believe that the incidence of secondtrimester abortion will ‘go away’. Policy should promote the provision of safe abortion not only as earlyas possible, but also as late as necessary.

Practice points

� Women presenting for abortion need to be offered appointments that enable them toproceed as speedily as possible, taking into account ambivalence in individuals.� All women of reproductive age need to be provided with clear information about abortion

procedures and unwarranted fears need to be allayed.� All women of reproductive age should be made aware they do not have to have reached

a definite decision to discuss the possibility of abortion with a provider.

Research agenda

� Understanding on the part of relevant professionals of the local abortion service, with the aimof clarifying local practice.� How relevant professionals discuss the safety of abortion and how abortion procedures work

with women, to improve the quality of this discussion.� Knowledge amongst women of reproductive age about the signs and symptoms of pregnancy.

E. Lee, R. Ingham / Best Practice & Research Clinical Obstetrics and Gynaecology 24 (2010) 479–489488

Acknowledgements

We would like to thank Marge Berer, editor of Reproductive Health Matters, for permission to usematerial already published in that journal in 2008, and Dr Nicole Stone and Dr Joanne Clements whoassisted with the data collection and analysis.

Conflict of interest statement

The authors have no conflicts of interest.

References

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