Memorandum 2
Submission from the Professor Ellie Lee,
University of Kent
(1) SUMMARY
This submission relates to the Committee's second
focus for inquiry, "Medical, scientific and social research
relevant to the impact of suggested law reforms to first trimester
abortions". Most such suggested reforms (for example removing
the requirement for two doctors' signatures, or reducing the number
required to one) seek to make early abortion easier to access.
One claim that has been made about the impact of such reforms
is that they may reduce significantly the proportion of abortions
carried out in the second trimester. The text here indicates,
in this light, what research suggests about the reasons for second
trimester abortions, ie what do we know about what women have
abortions at 13+ gestational weeks. The main points to emerge
are:
a) Changes to the law for first trimester
abortions, while justifiable on other grounds, will not lead to
the eradication of most abortions at 13+ weeks. This is because
most women who abort at this stage do not approach a doctor to
request abortion until a gestational stage of 12+ weeks. The primary
explanatory factor for this delay in requesting abortion is lack
of early awareness of pregnancy. This factor is especially important
for incidence of abortion at 18+ weeks.
b) Women who have abortions at 18+ weeks
often recognise pregnancy symptoms at an especially late gestational
stage. Abortions performed at 18+ weeks are the cause of a
great deal of controversy but since they have been the subject
of little research not much is known about the circumstances of
the women concerned. The knowledge we have suggests, however,
these women could not have sought abortion earlier on because
they did not realise they were pregnant until well into the second
trimester. Legal modification to the upper limit would clearly
impact on women in this position; they would be left in a position
of having to continue a pregnancy they were shocked to discover
and do not want to continue. This is a reality with implications
that policy makers must confront.
c) There are measures that could be taken
that might impact on patterning of abortion during the second
trimester without compromising the well-being of women. These
measures are not primarily legal, but concern the funding and
organisation of services, education of relevant medical staff,
and education of the fertile population, which may enable women
to abort at an earlier gestational stage. Some of these measures
have been proposed by the Chief Medical Officer.
(1) Reasons for delay. Many factors
contribute to second trimester abortions. A study of abortion
at 19-24 weeks found that for "most" women a combination
of factors led to late abortion (MSI 2005). The largest study
of second trimester abortion reported so far (Ingham et al
2007) found that 13 different reasons were selected by at
least one-fifth of the sample of 883 women who had terminated
a pregnancy at 13+ weeks who participated in the research.
| 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
| 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
(2) Time and delay. In terms of time, much of
the delay occurs before an abortion is even requested. Half
of the women in the study by Ingham et al (2007) were at 13+ weeks'
gestation by the time they first asked for an abortion. A
smaller study found, similarly, that late presentation for abortion
accounted for most second trimester procedures (meaning in this
study that only 13 percent of second trimester abortions were
defined as `preventable') (George and Randall 1996).
(3) Woman-related reasons for delay. As the table
above indicates, many reported reasons for abortion at 13+ weeks
are "woman-related", that is, they are not a direct
effect of problems of accessibility in the abortion service. Lack
of early awareness of pregnancy has emerged in all relevant
research as one of the most significant woman-related factors
for women requesting second-trimester abortions. The key factors
reported by women in Ingham et al (2007) which explained why they
did not realise they were pregnant earlier on were:
— Because my periods are irregular (49%)
— Because I continued having periods (42%)
— Because I was using contraception (29%)
As well as delays in suspecting pregnancy, women also report
delays between suspecting pregnancy and taking a pregnancy
test. The most commonly reported reason for this delay in
Ingham et al (2007) was also "woman-related"; women
reported they suspected they were pregnant but "didn't do
anything about it until the weeks had gone by". Others report
delay at this stage because they are `not sure about what they
would do if they were pregnant' and fears over the reactions of
their parents and partners. Second trimester abortion is also
strongly associated with a delay in deciding to have an abortion
and the most commonly reported reasons for this delay are
women's worries about what having an abortion involves, and difficulties
in agreeing a decision with their male partner. Notably, delay
between deciding to have an abortion and asking for one is
usually very short.
Abortions at over 18 weeks' gestation are especially associated
with delays in the earlier stages of the abortion pathway, which
are "woman-related". Women who abort at this stage
take longer to suspect pregnancy and to confirm the pregnancy
with a test than women who have abortions at earlier gestations.
Ingham et al (2007) found that 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, compared with 9 weeks' gestation for
those who had abortions at 13-15 weeks. Women who had an abortion
at 18+ weeks were also more likely to have experienced continuing
periods, which delayed the suspicion that they were pregnant.
(5) Service-related reasons for delay. While
`woman-related' factors emerge as important, relatively large
proportions of women terminate a pregnancy at 13+ weeks do so
because of delays in obtaining abortion cause by the abortion
service. Significant numbers of women report delays of more that
the maximum wait between requesting an abortion and procedure
of 3 weeks, recommended by the Royal College of Obstetricians
and Gynaecologists. Ingham et al (2007) found that the
majority of this service related delay is caused by a combination
of delays in obtaining appointments with the abortion provider
after referral, and delays at the referral stage. These findings
suggest in particular a certain amount of confusion about the
provision of second trimester abortion on the part of the first
health professional approached (most often a GP) about where to
refer women on to. There is also evidence that some referring
doctors' disapproval of abortion also causes delays (MSI 2005).
Ingham et al. (2007) found this was important for very late abortion;
a significant reason 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'.
(6) What could assist women to abort `as early as
possible'? Current policy rightly places emphasis on abortion
being provided as early as possible, and measures relating to
funding of services and encouraging wider use of Early Medical
Abortion (EMA) reflect this emphasis. It appears to have impacted
on the distribution of abortion procedures, with recent years
showing a shift in procedures away from the latter end of the
first trimester to the very early weeks. It could be that, similarly,
modifications to the law relating to abortion up to 12 gestational
weeks may assist further moves in this direction, but research
suggests they will have a relatively small effect for the overall
incidence of abortion at 13+ weeks. Most second trimester abortion
would be unaffected by legal modifications to access to early
abortion.
Recent changes in the provision of early abortion, which
have led to the shift noted above in the distribution of first
trimester procedures, do however indicate that policy modifications
can have a significant impact advantageous for public health.
If similar attention were given to second trimester procedures
as has been given recently to early abortion, it is likely some
significant gains could be made. It may be possible to shift the
patterning of procedures towards earlier stages of the second
trimester.
There are modifications to services that policy makers could
help to encourage. Delays for women who are already over 13 weeks
pregnant (esepcailly those who have abortions at 20 plus weeks)
do sometimes relate to problems at the point of referral, and
greater efforts by PCTs and service providers to address this
would enable some women to have an abortion at earlier point in
the second trimester. Increasing awareness amongst referring doctors
of local arrangements also appears to be a key issue. This echoes
the recommendation of the Chief Medical Officer in his 2005 report
about late abortion, who states for abortion at 20 plus weeks,
that "Primary Care Trusts, with the help of abortion service
providers, should identify sources of delay in accessing abortion
services and reorganise services accordingly in order that all
abortions can be carried out as early as possible" (CMO 2005).
Some recommendations in the CMO's report also refer to counselling
of women seeking late abortion. One specific recommendation is
that "The Department of Health should commission a review
of access to abortion services, including late abortions, to include
exploring the support and counselling given to women". Research
confirms the salience of this observation for the second trimester
as a whole, to address some "women-related" reasons
for delay. Some women report "worry" about what abortion
involves which contributes to their delay in making the decision
to ask for one. Finding ways to raise awareness of how abortion
works could address some of these concerns and so reduce delay.
Second, thought might be given to the implications of the finding
that many women report taking a long time to make their mind up
about having an abortion, and make contact with a doctor or abortion
provider only once that decision has been made. Promoting the
understanding that seeking help from an abortion service does
not imply a definite decision to have an abortion could help to
speed up the process between finally asking for an abortion and
obtaining one; in effect reducing "service-related"
delays reported at the stage between referral and abortion procedure.
Policy makers could also usefully consider how to address
a major factor contributing to delay, namely delay in women realising
they are pregnant. This is not an easy area to address, but policy
cannot honestly claim that other interventions will have the major
impact on the incidence of second trimester abortion.
September 2007
NOTES
1. The major study to date of second trimester abortion
in England and Wales published as "Second-trimester abortions
in England and Wales" by Ingham et al in 2007. This
study was carried out by the Centre for Sexual Health Research
at the University of Southampton, in association with the School
of Social Policy, Sociology and Social Research at the University
of Kent. Summary of the findings and the full report are available
here:
http://www.psychology.soton.ac.uk/research/cshr/
2. There are two smaller scale studies of second trimester
abortion in Britain previously reported:
George, A. and Randall, S. (1996) "Late presentation for
abortion", The British Journal of Family Planning, 22:
12-15.
Marie Stopes International (2005) Late abortion, a research
study of women undergoing abortion between 19 and 24 weeks gestation,
London, MSI.
3. There are some studies of this subject reporting on experience
in other countries. Given the variation in legal and service provision
contexts, they are not referred to here.
4. The Chief Medical Officer's report about the late
abortions service was published in 2005 as An Investigation
into the British Pregnancy Advisory Service (BPAS) Response to
Requests for Late Abortions, London, Office of the CMO.
| 
