Select Committee on Science and Technology Written Evidence

Memorandum 2

Submission from the Professor Ellie Lee, University of Kent


  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.
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


  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:

  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.

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