Late term abortions in Australia – Reasons
Sth Australia Abortion Coalition December 2018
Most abortions in South Australia occur in the first trimester of pregnancy but a small number of women need an abortion later in pregnancy. SA abortion law1 imposes a limit on the gestational age at which abortion may be performed, which is out of step with medical evidence, public opinion, and patient-centred health care.
SA has excellent services for the care of women needing second trimester abortion but each year a small number of women experience distress associated with the current gestational ‘cut-off’ and some are denied an abortion because of it. Others face the pressure of having to make a hurried decision to comply with the gestational limit. Abortions in the second or third trimester are rare in Australia and in other countries such as the UK. 2 3 4
SA data consistently shows the majority of abortions (91.9%) occur within the first 14 weeks, or first trimester of pregnancy. Abortions occurring at or over 20 weeks gestation account for about 2% of all abortions.
There are several reasons why women need abortions after 20 weeks gestation, and women do not delay seeking an abortion ‘needlessly’. Australian and overseas studies identify factors affecting the timing of the decision for abortion. 5 6 7 8
DIAGNOSIS OF FETAL ABNORMALITY
About half the small number of later gestation abortions (after 20 weeks) occur because of fetal abnormality. These diagnoses occur later in pregnancy, with the timing of tests and procedures that screen for and diagnose serious fetal abnormalities dictating the timing of a woman’s decision to abort. There is a range of screening tests in the first trimester. Some indicators then require further diagnostic tests but results may not be available until after 14 weeks gestation. If a decision is made to proceed to abortion it is usually then performed in the second trimester.
The next screening test is a morphology scan at 19 – 20 weeks gestation. Until this point in the pregnancy, many serious abnormalities will not be detectable. If abnormalities are identified on this scan, further investigations are often required including second ultrasound, genetic testing, fetal MRI, and referral to other specialists. Some complex clinical conditions can take even more time before a confident clinical picture or the safest time for abortion is determined.
SYMPTOMS OF PREGNANCY ARE NOT CLEAR
Later presentation for abortion may occur because the pregnancy has gone unrecognised by the woman, or has failed to be diagnosed by doctors. Some women continue to menstruate in pregnancy. When effective contraception is being used, pregnancy symptoms may be discounted. Long-acting methods of contraception, such as implants and IUDs suppress menstruation. Younger women or menopausal women, women with irregular bleeding or women with medical conditions, which make pregnancy unlikely, may not realise that they are pregnant.
DIFFICULT PERSONAL CIRCUMSTANCES
Women may be delayed in seeking abortion due to anxiety about confiding in their parents or partner, failure of anticipated emotional or economic support (from family, partner, or employer), or a change in socio-economic circumstances. Women experiencing domestic violence, mental or physical health problems, trauma, or addiction also experience barriers in organising care.
A recognised form of domestic violence, reproductive coercion includes a range of abusive, controlling behaviours by the woman’s partner, such as contraceptive sabotage, or forcing a woman to continue with an unwanted pregnancy. As this usually occurs in the context of violent relationships, women can find it extremely difficult and dangerous to access abortion services, causing significant delays in presentation.
DIFFICULTY ACCESSING ABORTION
Some women make a decision to have an abortion earlier in their pregnancy, but experience delays in access. Some women are given misinformation—sometimes deliberately—about abortion availability. Women living in rural, regional or remote locations experience delays because of long waiting times for appointments, specialist referrals, and travel times.
ILLNESS OR INJURY DURING PREGNANCY
While relatively rare, sometimes a woman experiences the need for a late gestation abortion due to illness or injury, such as serious trauma (eg from a car accident), the need for urgent cancer treatment or deterioration in other conditions.
The Royal Australian & New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recognises special circumstances of late presentation or diagnosis and support the availability of legal abortion without a gestational cut-off, so that women and their specialists can decide as late as necessary, avoiding the regret and suffering caused when decisions are made under the pressure of arbitrary (non-clinical) limits. 9 A 2008 peer-reviewed online survey showed a high level of support for access to lawful abortion and that a majority of Australians support laws which enable women to access abortion services after 24 weeks gestation. 10
Repealing laws restricting abortion from the criminal law will enable assessment by the woman’s specialist multidisciplinary team, and her own informed consent, to proceed with an abortion.