On 29–31 March 2007 the International Consortium for Medical Abortion (ICMA) convened a three-day conference in London to address second trimester abortion.Footnote* The conference was attended by 90 expert clinicians and advocates from Africa, Asia, Western and Eastern Europe, Latin America, the Caribbean, North Africa and North America.
Why did we decide to focus on second trimester abortions? Firstly, because they happen. Secondly, because almost no one wants to think about them. Thirdly, because too few clinicians want to provide them. But most importantly, because women need them – often the youngest and most vulnerable women. Second trimester abortion puts complex issues on the table regarding methods, values, stigma, the burden on providers of service delivery and the sometimes complicated reality of women's lives and decisions.
The conference sought to:
highlight the importance of second trimester abortion as a women's health, ethical and public policy issue;
review the situation with respect to second trimester abortion in relation to women's and providers' perspectives, safety and efficacy of methods, legal and policy dimensions, access and service delivery issues, and the contribution of second trimester abortions to maternal morbidity and mortality;
delineate the place of medical methods within second trimester abortion; and
provide a forum to share this information, start a process of developing guidance on these matters and disseminate the information globally.
It was striking to learn during the course of the conference that women all over the world have mostly the same and often multiple reasons for second trimester abortion, though the specifics differ. Confronting the fact of an unwanted pregnancy is not always easy and deciding to terminate it not always straightforward. This is often the case for young women, many of whom fail to recognise the signs of pregnancy or cannot acknowledge them because the consequences are too great. Others wait in hopes of being able to get married. Some women need time to sort through social pressures, religious beliefs or changes in their relationships to make the decision. For other women, drastically changed circumstances (e.g. violence starting in pregnancy or abandonment by partner), a diagnosis of fetal anomalies, and in some cases pressures to practise sex selection, cause them to seek an abortion after initially intending to carry a pregnancy to term.
Where maternal mortality is high, complications and deaths from unsafe second trimester abortion procedures are rarely mentioned, but they account for a disproportionate number of abortion-related deaths. In both developed and developing countries where second trimester abortion is legally restricted, barriers in law and regulations and lack of services and trained service providers, make it more difficult to find an abortion provider. This either pushes women towards unsafe procedures or forces them to travel, including to other countries, for a safe abortion. Second trimester abortions, safe or unsafe, cost more, and finding the money may be difficult and time-consuming, making these abortions later than they need be.
Around the world, different levels of health care resources, laws on abortion that are more restrictive in the second trimester than in the first, provider preference and varying levels of access to medications, instruments and training, determine how accessible these abortions are and which methods are available. Thus, although a growing number of countries provide both surgical and medical abortion in the first trimester, there is mostly no choice after 14 weeks of pregnancy.
It was dismaying to learn that in many developing country settings, higher risk second trimester abortion methods, both medical and surgical, including some that take up to a week to complete, are still in use. These include ethacridine lactate, hysterotomy and Kovac's, none of which are recommended by the World Health Organization. We are already seeing discussion and action to replace these methods in a number of countries since the conference, and hope this publication will help to move individual providers and national policy towards WHO-recommended methods only – currently, dilatation and evacuation (D&E), mifepristone–misoprostol, and where mifepristone is not available, misoprostol alone.
Quality of care is an important aspect of making second trimester abortion safe and accessible. This is limited by lack of resources and health system support and a serious shortage of second trimester abortion providers worldwide. In some countries, higher malpractice insurance rates, lack of adequate financial reimbursement and lack of good facilities discourage physicians from seeking training. While GPs, nurses and midwives could be trained to provide second trimester medical abortions safely with appropriate back-up, and surgical technicians could learn D&E, law and policy, and often physician opposition, prevent consideration of these alternatives.
Even in countries that support legal abortion, political support tends to diminish as pregnancy advances. For some people, the moral balancing of women's rights and fetal rights changes as a pregnancy progresses; for some, this pushes aside the right of the woman to control her own body. There is little understanding of the reasons why women need later abortions, and little empathy for them or the clinicians who provide them, or for the ethical perspectives of women and providers themselves. Those who are willing and committed may become the targets of anti-abortion fanatics, or banned by legislation from using the safest methods. Spurious information, promulgated by anti-abortion organisations, e.g. about whether fetuses feel pain and when a fetus is viable, are also contributing to public discomfort in some countries. Given these sentiments, many clinicians are unwilling to do second trimester abortions, especially after 20 weeks of pregnancy. Neither women nor providers find these abortions easy to go through either; however, that does not make them less necessary.
Both the lack of compassion for women who need second trimester abortions and the marginalisation of abortion providers within medicine can and should be addressed through values clarification workshops. Most important, perhaps, is addressing the ambivalence towards second trimester abortion that prevents politicians, parliamentarians, health system managers and clinicians from actively supporting good quality, accessible and affordable second trimester abortions services.
The papers in this publication, most of which were initially presentations at the ICMA conference, cover all these subjects.
Advocates for women's right to safe, legal abortion need to open a window on the existence of second trimester abortions in their countries. We call on those working in law, government, medicine and media who support a woman's right to decide on abortion to work to achieve the aims of the ICMA conference and implement its recommendations, which can be found at the end of this publication.
Notes
* International Conference on Second Trimester Abortion. London, 29–31 March 2007. The conference report and presentations are available at: <www.medicalabortionconsortium.org/events/international-conference-on-second-trimester-abortion-56.html>.