Second trimester abortion: law, policy, service delivery and advocacy issues'

1

• Second trimester abortion law, policy,
  service delivery and advocacy issues.
• Overview of the discussions and recommendations
  from ICMA Conference on second trimester
  abortion,
• London, March 2007
• Dr Rodica Comendant,
• ICMA Coordinator

2
Objectives

• To give an overview of the issues on second
  trimester abortion discussed at the ICMA
  conference that took place in London in March
  2007.
• To present the main recommendations from the
  conference.

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The Need for Second Trimester Abortions

• How late in pregnancy abortions should be
  permitted and carried out is a matter of great
  controversy among almost everyone except the
  women who need them
• In every country, second trimester abortions
  take place, legally or otherwise, or women travel
  elsewhere to obtain them. Laws either create
  access or create barriers...
• Marge Berer, ICMA Chair, RHM Editor

4
Reasons for 2nd trimester abortion

• Difficulties in recognizing their pregnancies
  during the first trimester
• Difficulty of taking the decision to terminate
  the pregnancy
• Circumstances change
• Fetal indications are mostly not identified until
  16, 18, 20, 22 weeks.

5
Barriers causing delays

• Services are not always accessible.
• When it is difficult to find someone to do a late
  abortion, the abortion becomes even later.
• Because of legal restrictions, many women are
  forced to travel, including to other countries,
  and/or pay for the abortion.

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Factors limiting the access

• Legal restrictions
• Increased stigma for women needing later
  abortions and for the clinicians who provide
  them
• Decreased number of providers willing to carry
  out late abortions, lack of training
• Lack of appropriate facilities and supplies

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The consequences

• Only 10 of all induced abortions occur in the
  second trimester, but
• these abortions are responsible for two thirds
  of all major complications (WHO 1997).
• In legally restricted settings, morbidity and
  mortality rates are also greater from
  complications of second trimester abortion
  compared to first trimester procedures.
• Deaths from these abortions are often hidden in
  the statistics on maternal deaths (Walker et al).

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Laws and Policiesa wide variation in the
countries regulation of second trimester
abortion

• Some countries allow second trimester abortion
  for broad therapeutic, economic and social
  reasons
• Some- liberally interpret health/mental health
  exceptions
• Many impose specific restrictions, including the
  need for approval by commissions
• Some allow second trimester abortions only to
  preserve the health or life of the mother, for
  fetal indications, and/or when the pregnancy is
  the result of rape or incest.
• Some countries have unclear laws on what
  constitutes a legal second trimester procedure.

9
Second trimester abortion
methods

• Vacuum aspiration up to 16 weeks LMP, dilation
  and evacuation (DE) or medical methods (using
  either mifepristone misoprostol or misoprostol
  alone) are the methods recommended by WHO as
  being safe and efficient. Both have advantages
  and disadvantages
• Outdated and dangerous methods such as dilation
  and curettage, sharp curettage, hysterotomy,
  intra-amniotic injection of hypertonic saline
  solution, intra-or extra-amniotic administration
  of ethacridine lactate (Rivanol), parenteral,
  intra or extra-amniotic administration of
  prostaglandin analogues and administration of
  oxytocin are still used in some settings.

10
Service Delivery Issues

• Finding staff who are supportive of women having
  2nd trimester abortion and making sure that they
  are well trained
• Setting policies about the viewing of the fetus
  and disposal of fetal tissue that comply with the
  law and respect womens choices
• Ensuring adequate space for women waiting for
  services and for recovery and
• Availability of equipment, medicines and supplies
  to provide medical abortion and to treat any
  complications.

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A universal service delivery issue - the shortage
of second trimester abortion providers

• The number of skilled second trimester surgical
  abortion providers is declining, new providers
  lack access to caseloads for learning and/or are
  less willing to learn this procedure.
• Higher malpractice insurance rates, restrictive
  laws, lack of adequate financial reimbursement,
  and lack of good facilities also discourage
  physicians from providing later abortions
• Those who do provide the service have heavy
  caseloads
• These lead to a risk of clinician burn-out

12
Advocacy issues

• Little understanding of the reasons why women
  need later abortions, and little empathy for
  these women or the clinicians who provide them.
• Sex selection abortion Challenging and reducing
  sex discrimination rather than regulating
  abortion services is the only solution.

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Advocacy issues fetal pain viability

• The fetus prior to 26 weeks does not experience
  pain the developmental processes necessary for
  feeling pain occur later in pregnancy
• Babies born before 28 weeks gestation have a very
  poor survival rate and often have multiple and
  serious developmental problems.

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Conference Recommendations

• While it is important to support improved access
  to sex education, contraception and first
  trimester abortion, access to good quality second
  trimester services is an essential part of
  comprehensive safe abortion services.
• Advocates must work to build support for safe,
  legal abortion in the second trimester of
  pregnancy. This work should include
• developing better data on the occurrence and need
  for second trimester abortion,
• the elimination of legal, regulatory and social
  barriers to second trimester abortion,
• a commitment of resources to training clinicians
  to provide later abortions, and
• research on the best medical methods in different
  settings.

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AcknowledgementsThis presentation has been
prepared based on the presentations during the
conference and the report on the conference,
prepared by Susan Yanow

• ICMA conference on second trimester abortion
  presentations and recommendations and a
  comprehensive Information Package on medical
  abortion can be accessed at www.medicalabortioncon
  sortium.org