Can the need for later abortions be prevented? The British experience suggests not without prohibition.

"AS EARLY AS POSSIBLE" IS A caveat that even the most ardent prochoice advocates would apply to abortion. Few people are entirely comfortable with the idea of second-trimester abortions. Most people, including abortion-providing doctors and abortion-seeking women, have a personal threshold beyond which they find abortion unacceptable. It's a subjective, often irrational and arbitrary, judgment. But it means that while early abortion is a common procedure, later abortions are relatively uncommon.

In Britain, the law regarding abortion on mental health grounds, which is broadly interpreted to include unwanted pregnancy, is the same at three weeks gestation as it is at 23 weeks. Yet, of the 198,000 abortions for residents of England and Wales that took place in 2007, just over 139,000 took place between three and nine weeks gestations and just fewer than 3,000 took place between 20 and 24 weeks. (Department of Health, "Abortion Statistics 2007")

The reason why there are so few "late abortions" is simply that women don't want to have them, and doctors don't want to do them. Curiously, until 1990 there was an upper time-limit of 28 weeks in England and Wales but no legal time-limit in Scotland--yet no abortions at all were registered in Scotland at gestations later than 26 weeks in the entire period from 1967 to 1990.

There are, of course, sound reasons for wanting to reduce the number of later abortions. The risks of abortion, although they remain small at all gestations, increase as the pregnancy advances. The procedure becomes more complex, and the experience is typically more distressing for all involved--particularly the pregnant woman.

In Britain, an immense amount of effort has been invested, by providers and the government, into reducing the number of later abortions by removing barriers to access for early treatment, yet the need for these procedures has remained at a constant level, suggesting that it may be resistant to policy. Later abortion may be a need dictated by circumstances that often only become apparent in later pregnancy but which must be recognized if we are to respect, and respond to, women's need for reproductive choice.

The British media has used many column inches speculating why any woman would be careless or callous enough to need one. Compared to the US and much of the rest of world, in Britain the need for abortion at all would appear to be minimal. Contraception is provided completely free of charge from family doctors and specialist clinics. Sex and relationships education is provided in some form in most schools. Young people--including those under 16--have access to confidential sexual health services without requirements for parental notification. In Britain there is debate about the quality of both service delivery and education; but no one can claim, as in many countries, that women are unable to access free birth control. The reasons for Britain continuing to have one of the highest abortion rates in the developed world are discussed elsewhere (for example, in my article, "Abortion: A solution to a problem," Abortion Review, March 2008), the point argued here is simply that many of the policy initiatives expected to prevent abortion already exist in Britain, yet the need for later abortion remains.

The political and administrative commitment to provide procedures as early as possible in Britain has been real and practical. In its official Statistical Bulletin on abortion ("Abortion Statistics, England and Wales, 2007") the Department of Health states explicitly that this is policy (Para 4.3.2). Furthermore, it documents the measures that the government has been prepared to take to improve access to abortion.

"In 2001," it reports, "the government set a standard of a maximum waiting time of 3 weeks. Significant investment was made to improve early access and [health service] performance in this area was measured." Furthermore, additional state funding was made available to support early abortion access initiatives and, in general, women's need to pay for their own procedures significantly reduced with only 11 percent paying for their treatment in 2007 compared with 26 percent 10 years earlier.

Yet, evidence shows that, while this has been hugely successful in increasing the proportion of very early abortions, it has done nothing to reduce the need for procedures between 20- and 24-weeks gestation. In the 10-year period to 2007, the proportion of abortions carried out between three and nine weeks rose to 70 percent from 56 percent of the total. The proportion of abortions provided at gestations greater than 20 weeks remained constant at between one and two percent. In essence--early abortions were accessed earlier but the proportion of later abortions remained the same. This has surprised and frustrated many policy makers, who assumed that later abortions were a consequence of either women being denied access to, or funding for services and that "the problem" would be resolved if these matters were addressed.

In the summer of 2008, the British parliament debated the abortion limit with a view to reducing it. In anticipation of the debate, the reasons why women present for later second-trimester abortions were scrutinized. An academic study using quantitative and qualitative analysis identified that women seeking second-trimester procedures did so because they:

* Had not realized they were pregnant, or not thought that the pregnancy was advanced as it was

* Had difficulty deciding whether to continue the pregnancy

* Had been confronted with difficult life problems, often with relationships, that made them feel it is impossible to continue with an originally wanted pregnancy.

There were some women who faced difficulties accessing services, or where medical problems had been identified, but these were the minority. (Ingham, Lee et al, "Second Trimester Abortions in England and Wales," Centre for Sexual Health Research, 2007)

Similarly an audit of all women with gestations greater than 22 weeks requesting abortion from abortion clinics run by bpas, during a 28-day consecutive period presented similar findings. (bpas, "Case studies show women's need for 24-week limit," May 2008) A review of 32 clients included a significant proportion who had been shocked to discover their pregnancy was so advanced. They had not realized they were pregnant either because they were using a contraceptive consistently that they thought could not let them down, or were amenorrheic (often due to prescribed medication, such as methadone, a medication used by those in substance abuse programs). Those who were aware of their pregnancy delayed their abortion request because they were struggling--either with the decision to end the pregnancy, or because they were trying to make it possible to keep their baby. Many eventually decided on this abortion reluctantly for the good of their existing children.

Policymakers can easily forget that for many women abortion is a decision that is very hard to make, and that they need time to reach it. Those of us who provide services are all too familiar with the cancelled, re-booked, again cancelled and again re-booked appointments by women who know in their hearts that an abortion is the best decision, but cannot face it at that moment. Given the intensely complex, personal and moral nature of the decision to end a pregnancy, it should be no surprise that some women take a while to reach their conclusion.

It is undeniable that many later abortions, worldwide, could be prevented if the will existed to do it. It may be that, in countries where access to birth control is difficult or expensive, where sex and relationship education for young people is poor and where maternity benefits are inadequate, improvements in these measures could reduce the number of all abortions by making it more possible for women to prevent unwanted pregnancy, or to continue pregnancies that are now ended. It may be that, in countries where access to abortion is stigmatized, difficult or expensive, that measures to reduce such obstacles may allow women to present earlier and so reduce the number of later abortions. But evidence from Britain suggests that there will always be some women who will need the option of later abortions if their reproductive choice is to be respected and their health-care needs met. In Britain, it seems, the prevention of later abortions would seem to mean either restricting access, or legal prohibition. Neither option should be given a moment's thought by those who consider, with humanity, the circumstances of women who request this care. (Ann Furedi, "Who Is Ethical, Who Is Moral?" Abortion Review, June 2008)

Clearly, later abortions are less acceptable to the public and policymakers and the service is more difficult to deliver. It could be argued that at this time it is expedient to build a consensus in support of early abortion--where there is less public and political resistance--by sacrificing our defense of the need for later abortions. After all, the number of early abortions is great, the number of later abortions relatively tiny. Those of us in the prochoice community have our own choice to make. Do we struggle against these obstacles to give women the time they need? Or do we perpetuate a myth that if only women were better educated and resourced later abortions would require no defense, because there would be no need for them? As women struggle to make their choice, so we as a community of advocates must make ours.

ANN FUREDI is the chief executive of the sexual health-care charity bpas (the British Pregnancy Advisory Service).