Second-trimester abortion: logistics and lack of symptoms are factors.

By the time they suspected and confirmed their pregnancies, more than half of patients seeking a second-trimester abortion at a California clinic had already missed the opportunity to have a first-trimester abortion. (1) In a study that asked women to identify factors that delayed their efforts to obtain an abortion, those who sought an abortion during the second trimester reported greater delays than first-trimester patients at each step of the process, from suspecting that they were pregnant to coming to the clinic. Moreover, logistical problems, such as difficulties in finding a provider, were widespread and contributed to delays for almost two-thirds of second-trimester patients.

Twelve percent of abortions in the United States are performed during the second trimester, when costs, complications and mortality are higher than in the first trimester. Because much of the literature on delays in obtaining abortions is outdated or has focused on narrow subgroups (e.g., adolescents), the researchers studied current factors associated with delay in a sample of 398 women who sought an abortion at a hospital-based clinic in San Francisco in 2001-2002; the sample was split about evenly between first- and second-trimester patients. Before they received their abortion, participants completed a computer-assisted self-interview that collected information about demographic, social and medical variables, as well as information on the timing of key steps leading up to the abortion. The primary outcome was gestational duration at the time of the procedure.

Bivariate analyses revealed numerous differences between first- and second-trimester patients. Participants who obtained second-trimester abortions were significantly more likely than their first-trimester counterparts to have had trouble finding an abortion provider (45% vs. 26%), to have been referred from other clinics (86% vs. 58%), to have had previous second-trimester abortions (31% vs. 15%) and to be unsure of the date of their last menstrual period (37% vs. 23%). In addition, they were less likely than first-semester patients to report pregnancy symptoms, such as nausea or vomiting (68% vs. 81%). Roughly two-thirds of women in each group said they had been using contraceptives at the time of conception.

Mean gestational duration was 70 days greater in the second-trimester group than in the first-trimester group. About half of the difference was due to the extra time it took for second-trimester patients to suspect that they were pregnant (28 days after missing their period, compared with six days in the first-trimester group) and to obtain a positive pregnancy test (28 days after suspecting the pregnancy, compared with 15 days in the first-trimester group). As a result, by the time their pregnancy was confirmed, 58% of women who eventually underwent second-trimester abortions were already in their second trimester. However, durations were also longer in the second-trimester group than in the first-trimester group for each subsequent step in the process of obtaining an abortion: deciding to get an abortion, calling an abortion clinic, calling the study clinic and arriving for the abortion.

Overall, 64% of women in the first-trimester group and 86% of those in the second-trimester group cited at least one factor that delayed their abortion. Logistical problems were especially common, causing delays for 63% of second-trimester patients and 30% of first-trimester patients; in particular, women who had abortions in their second trimester were significantly more likely than women in their first trimester to say that they had difficulty finding a provider (20% vs. 7%), were initially referred to a different clinic (47% vs. 13%) and had difficulty arranging transportation (10% vs. 4%). Nearly a third of the second-trimester group and a fifth of the first-trimester group said that a logistical factor (as opposed to emotional, financial, interpersonal or other factors) caused the most delay for them. Women in their second trimester were also significantly more likely than first-trimester patients to attribute delays to not suspecting pregnancy (34% vs. 20%), to problems in obtaining Medicaid coverage (7% vs. 2%) and to difficulty in deciding to have the abortion (30% vs. 20%).

After adjustments for numerous demographic, medical, logistical, emotional and interpersonal variables, multivariate logistic regression revealed several factors associated with an increased risk of second-trimester abortion: prior second-trimester abortion (odds ratio, 5.9), difficulty in obtaining state insurance (4.4), initial referral elsewhere (4.1), difficulty in finding a provider (2.3) and uncertainty about the timing of the last menstrual period (2.3). Women had a reduced likelihood of second-trimester abortion if they had nausea or vomiting (0.4), had had a prior abortion (0.4) or used contraceptives (0.4).

The findings underscore the need for second-trimester abortion to remain legal and accessible, the researchers note, as "many women seeking second-trimester abortions simply lacked pregnancy symptoms or were unaware of their last menstrual period and therefore took a long time to recognize and test for pregnancy" Public health measures that may reduce the prevalence of second-trimester abortions include improving access to contraceptives, providing low-cost home pregnancy tests and educating patients about the importance of keeping track of menstrual periods. However, "because of the individual nature of many of the reasons for delay, it is unlikely that public health measures alone" can greatly reduce the number of late abortions.--P. Doskoch

REFERENCE

(1.) Drey EA et al., Risk factors associated with presenting for abortion in the second trimester, Obstetrics & Gynecology, 2006, 107(1):128-135.