Abortion: better ‘late’ than never

Though the issue of ‘late’ abortion is hotly debated, there has been surprisingly little research done on a crucial question: why do women seek abortions so late in pregnancy? A recently published paper has gone a long way to filling this gap by asking women who had abortions between 13 and 24 weeks into pregnancy to explain their reasons for doing so. The research has been widely reported and commented on, particularly in the UK. Here, Dr Ellie Lee, a member of the research team, discusses the context for the research, and summarises some of its findings.

As articles about abortion on spiked have noted, the abortion controversy has shifted more and more towards a focus on ‘late’ abortion. Ultrasound pictures of ‘walking’ fetuses, media reporting of ‘miracle babies’ born early at 22 weeks but surviving, and horror stories of ‘botched abortions’ where fetuses briefly show signs of life after late abortion procedures, have often set the terms of recent public debate.

There has always been a host of myths and misconceptions about abortion, but these debates have added new ones to the list. These include misunderstandings about science, and what it tells us about fetal development (see The wrong debate about abortion rights by Ellie Lee). They also include confusions about the circumstances and experiences of women who have late abortions.

All women who have abortions are the subject of widespread misunderstanding. Ignorance about their circumstances is reflected in negativity about abortion by commentators who seem unable to comprehend why a woman ever becomes pregnant when she does not plan to. This approach shows a profound lack of knowledge of contraceptive methods and their failure rates, and a lack of insight into the nature of sex and relationships (1). As a result, unfortunately, women who have abortions rarely appear in the public debate as what they are: ordinary women, from all walks of life, who most often seek abortion because they happen to have become pregnant accidentally through contraceptive failure. Instead, they are usually presented as possibly deserving victims (if they have got pregnant from rape or incest, for example) or they are imagined to be ‘selfish career women’ or ‘slappers’ who ‘use abortion as contraception’.

When it comes to late abortion, ignorance about the women concerned and the nature of their experiences seems even greater. This is reflected in the fact that late abortion is often discussed without reference to women at all, as if the ‘walking fetuses’ or ‘born alive fetuses’ were never inside a woman, who in turn played no significant part in their gestation or consideration of their future. If the women concerned are brought into the picture, it is often with incomprehension – ‘how could they possibly end up five months into a pregnancy and not have sorted themselves out sooner?’

Consequently, discussion of late abortion has tended to produce more heat than light. This is a problem arguably compounded by the notion, popularised by some who are pro-choice, that the ‘problem’ of late abortion could be made to ‘go away’ if early abortion were made easier to access. This argument tends to add to the perception that late abortion is inherently problematic and purely a byproduct of the way the abortion service is run (see We still need abortion as early as possible, as late as necessary, by Ellie Lee).

In this context, I was delighted to have been recently involved in a research study that sought to examine the real reasons why women have abortions at 13 to 24 weeks of pregnancy. In all, 883 women participated in the research. The study has raised a raft of interesting points, including the following:

• A major reason for delay in the pathway to abortion is due to women not realising that they are pregnant. This was the case for many women in our study because they normally had irregular periods and so did not consider missing periods to be a sign of pregnancy. Many also reported what appeared to them to be ‘continuing periods’ (probably light bleeding that did not progress further to lead to miscarriage). And for many women, the fact they were using contraception meant the possibility of falling pregnant was simply not on their minds. These were major reasons why half of the women questioned were already more than 13 weeks pregnant by the time they requested an abortion.
• After requesting an abortion, delays were partly service-related. Delay at this stage was caused by difficulties in getting further appointments, and by confusion amongst doctors first approached (mostly general practitioners) about where a procedure should take place. These sorts of confusions may be related to the fact that the abortion service in many areas has become complex. Primary Care Organisations, which are responsible for commissioning health services for the local area, are likely to purchase abortion services from a range of providers. National Health Service (NHS) hospitals often look after women having abortions in early pregnancy, but in many areas later abortions are increasingly provided by independent abortion providers such as the British Pregnancy Advisory Service (bpas). Unless measures have been taken to make sure relevant health professionals know how to refer women speedily to the right place, confusions about where women need to go to obtain their abortion lead to delays.
• Forty-one per cent of women in the study said they were unsure about having an abortion and therefore it took some time to make up their minds. Many reported that various aspects of relationships with their partners and/or parents (especially for younger women) played a role in delays in their decision-making about whether to have an abortion. Twenty-three per cent overall said their relationship with their partners had broken down or changed following confirmation of the pregnancy. This indicates that, for some women, the decision to have an abortion is also a decision about whether to become a parent or have another child, and is dependent on broader changes and complications in their personal lives.

Overall, these findings can provide the basis for a more useful discussion of abortion than we have had here in Britain lately. They show, first, that there are ‘service-related’ reasons for delayed abortions, and therefore that practical measures should be taken to help women obtain abortion as early as possible. In particular, if effort was put into minimising delays at the point of referral for abortion, then gains could be made. If this very real, concrete problem leading to later abortion became a talking point, it would make more difference to the incidence of late abortion than any amount of discussion about whether a fetus can or cannot smile.

The findings also show that there are many ‘women-related’ reasons for late abortion. These are more nuanced and a policy solution is less obvious. Contraception fails women, pregnancy symptoms are misidentified as such, and women’s relationships are sometimes unpredictable. These sorts of reasons indicate that late abortion is not simply an abstract moral problem, but a reflection of everyday, real life.

In the end, a key point to press is that women who have abortions at 13 to 24 weeks’ gestation are just like the rest of us. How many of us can honestly say we cannot imagine misreading what is happening to our body when we are pregnant, especially if we have never been pregnant before? How many of us cannot put ourselves in the shoes of the woman who finds that her partner does not react in the way she expected to the news that she is pregnant? How many of us who have children can say, hand on heart, that any and every future pregnancy, whatever our circumstances, would always be unequivocally welcome?

To seek to understand the choice for abortion is to seek to understand the nature of everyday, normal problems and experiences for women. Let us hope that more people engage with these problems in the future.

Ellie Lee is a lecturer in social policy at the University of Kent.

Read a summary of the research findings: Second-trimester abortions in England and Wales by Roger Ingham, Ellie Lee, Steve Clements and Nicole Stone, University of Southampton Centre for Sexual Health Research [pdf].

See also: Why do women have late abortions, Abortion Review, 19 April 2007. Ellie Lee discussed the research on BBC Radio 4’s Woman’s Hour (listen here).

(1) For a recent example of this, see A crisis brought on by our selfish desires, The Times (London), 17 April 2007