by Jennifer Daw Holloway, Ipas

11 October 2012


If you work in reproductive health or public health you often hear people talking about the “unmet need for contraception” in a certain country or region. But here’s an unmet need that never gets discussed outside of small circles: second-trimester abortion.


Millions of women die or are disabled every year from unsafe abortion. Two-thirds of the women who suffer or even die are those who had an unsafe second-trimester abortion. No one really wants to talk about it but second-trimester abortions are often a medical emergency. And if they’re performed unsafely, women die. But with appropriate provider training, we can save women’s lives.


In the United States, most women who end up seeking a second-trimester abortion are disproportionately young and poor. They may not recognize signs of pregnancy early on, or they may delay seeking care for financial reasons. And then there are health reasons for later abortion, such as in cases where a wanted pregnancy goes horribly wrong and either fetal abnormalities or the woman’s health make the procedure necessary.


In the rest of the world, the picture is much the same. There is one difference, however: As many barriers to safe second trimester abortion as exist in the United States, barriers are that much greater in the global south. Many women facing complications from unsafe procedures have nowhere to get follow up care. And many women don’t make it.


At the World Congress of Obstetrics and Gynecology (FIGO 2012), now underway in Rome, Italy, Ipas and the FIGO Working Group on the Prevention of Unsafe Abortion sponsored sessions on second-trimester abortion in low-resource settings. In Nepal, for example, where safe abortion-including second-trimester abortion-is integrated into the national health system, providers have to turn some women away for various reasons… only to find that despite warnings and counseling, the woman sought an unsafe procedure and was seriously injured or even killed. Providers remember these women’s faces and their stories; they recall the woman’s fear and emotional pain like it was just yesterday.


Dr. Alfonso Carrera, a Mexican gynecologist, says in the last year he has seen 160 second-trimester abortion cases. Why? The health system failed these women. Some have been raped, he says. Some are just teenagers. With few options and few resources, they come to him because other health facilities won’t see them. “One woman said if I couldn’t help her she would kill herself,” he says with tears in his eyes.


Another doctor in Africa says he only knows of a handful of providers in his country who will perform a second-trimester abortion-and all are in a major city, hundreds of miles from women in rural provinces.


In Ethiopia, 20 to 40 percent of women seeking abortion are second-trimester cases. In South Africa, roughly 25 percent of abortions are performed in the second trimester. Like in other countries, despite the law allowing for abortion up to a certain point in second trimester, some facilities set their own guidelines, shortening the time period during which they’ll perform a second-trimester abortion. Providers are often reluctant to perform these abortions because of stigma. A nurse in South Africa said “other professionals call you a murderer.”


And don’t forget the stigma women face. In Colombia, women are sometimes given the fetal remains in a plastic bag, or are put in the labor ward-seemingly as punishment for their decision to terminate a difficult pregnancy.


But, second-trimester abortion services are achievable even in low-resource settings. Providers need clinical and networking support from colleagues. In Nepal, providers have developed an exchange program with providers in Ethiopia, another country where second-trimester abortion care has been improved with legal reform and buy-in from the government. The World Health Organization’s most recent safe abortion guidance includes recommendations on abortion after 12 and 14 weeks.


Providers around the world who are willing to perform second-trimester abortion care all agree: The challenges and barriers are great. They call for more training, particularly for whole-site training to sensitize all staff, even those working in reception or in janitorial positions.


For both women and providers, this is no easy decision. As advocates for women’s sexual health and rights, should we dismiss this population’s rights? Safe abortion is part of the spectrum of reproductive health care. How can we ignore this unmet need for safe second-trimester abortion services?


Unsafe abortion kills 47,000 women every year and leads to complications for millions of women. The risk of death and disability for women undergoing unsafe abortion in the second trimester is particularly high, say Dr. Lisa Harris of University of Michigan and Dr. Dan Grossman of Ibis Reproductive Health in a commentary published in the International Journal of Gynecology and Obstetrics. Therefore, efforts to reduce unsafe abortion and improve maternal health cannot neglect second-trimester services.


Although second-trimester abortions account for a minority of all abortion procedures, unsafe second trimester abortions are the cause of the majority of serious abortion-related complications and death, especially in low-resource settings where the vast majority of unsafe abortions take place. Yet in many countries second-trimester services are not readily available, owing to a lack of trained providers and widespread stigma. Even in countries where later abortion is legal, women still face barriers in accessing the service.


In order to address these barriers, more providers should be trained to perform second-trimester abortions and second-trimester services must be mainstreamed into health services around the world. Access to safe and acceptable medical induction could be greatly expanded by registering mifepristone for second-trimester use and making the drug widely available. In addition, research is urgently needed to determine the extent of the unmet need for safe second-trimester services and to address gaps in clinical knowledge, especially about how to best scale up these services in low-resource settings. Ibis is currently conducting research on these topics and will soon share results from a South Africa study.

While one strategy to reduce unsafe second-trimester abortion could be to help women access abortions earlier in their pregnancies, data show that the rate of second-trimester abortion has remained relatively constant over time, despite advances like the introduction of medication abortion, which has allowed more women to access abortions before nine weeks of pregnancy. Efforts should continue to help women get earlier abortions, but the need for second-trimester abortion will not go away. In order to save women’s lives and improve women’s health everywhere, second-trimester abortion must be included in global and local strategies to improve access to safe abortion.


Citation: Harris LH, Grossman D. Confronting the challenge of unsafe second-trimester abortion. Int J Gynaecol Obstet 2011;115(1):77-9


Read the abstract.

For more information, contact Britt Wahlin.