Second trimester abortion law globally: actuality, trends and recommendations
Research Associate, Harvard School of Public Health, Boston MA, USA. E-mail: firstname.lastname@example.org
Although the great majority of abortions are performed in the first trimester, a significant number are not carried out until the second trimester .Data on the global incidence of second trimester abortions are difficult to obtain due to the lack of any statistics in countries where abortion is legally restricted.1 However, estimates have placed the percentage at 10–15%of all abortions , . For example, studies have indicated a rate of 13% in the United States and Nigeria, 10% in Canada and Singapore, and 25% in India and South Africa , . This is a significant number in light of the fact that an estimated 42 million abortions (figure for 2003) are performed every year, of which 21.6 million (figure for 2008) are unsafe . Unsafe second trimester abortions constitute a serious public health problem; they account for two-thirds of the five million estimated admissions to hospital annually for complications of unsafe abortion , . They are also responsible for a disproportionate number of abortion-related maternal deaths, even though in some cases they may be misclassified as due to other causes , .
Historically, there has been little discussion in the literature of second trimester abortions and limited research on the reasons women have them. However, in recent years this has begun to change. In 2008 Reproductive Health Matters published a journal supplement on second trimester abortion, with papers from the 2007 International Conference on Second Trimester Abortion  Studies from England and Wales, Mozambique, Netherlands, Spain, South Africa, United States and Viet Nam, demonstrate that the factors influencing the need for second trimester abortions are present in almost all societies , , , , , , , . For example, some women do not realize that they are pregnant or are in denial about their pregnancy until the second trimester. Other women face pressure from family members or partners which delays their making a decision, or they are themselves undecided about what course to take. Some decide not to continue a wanted pregnancy after facing difficult altered personal circumstances or a diagnosis of serious fetal anomaly. After the decision to have an abortion is made, other factors can cause delays. These include lack of money to pay for the abortion, lack of information on where it can be obtained, the need to travel long distances, including to another country, to find an abortion provider, concerns about what is involved in undergoing an abortion, and delays in getting a pregnancy test or obtaining a clinic appointment. In addition, the stigma associated with second trimester abortion can cause further delay. These factors are particularly serious for young women, women with little education, poor women, and rural women. Finally, threats to health and life often do not arise until the second or third trimester of pregnancy, and many tests to detect fetal abnormalities cannot be carried out until well into the second trimester , , , .
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|1. Legal status of second trimester abortion|
In light of the need for second trimester abortions, one of the most important factors determining whether they can be safely obtained in a timely fashion is the law governing them and restrictions placed on them. Although there is a substantial body of academic literature on the legality of abortion in various countries, most of it focuses on the lawfulness of abortion in the first trimester , , , , , , . Analyses of the legalityof abortion often do not specify indications or requirements for abortions performed later in pregnancy. This paper focuses on the legality of the procedure in the second trimester and is based, in all but a few cases, on the exact wording of the specific laws and, when available, in regulations for some 191 countries for which information is available . It is structured around an analysis of the legality of second trimester abortion according to the most common indications for such abortions which appear in the laws themselves: to preserve the woman's life, physical and mental health reasons, pregnancy due to a sex offence, fetal impairment, socio-economic reasons, and at the woman's request.
|2. Abortion to preserve the life of the pregnant woman|
Almost all countries or jurisdictions in the world with specific laws on abortion allow abortion to preserve the life of the pregnant woman. Their laws specify this indication explicitly or, under general criminal law principles of necessity, are interpreted as permitting such abortions. In most cases, no upper time limit is set by these laws, and thus the laws can be presumed to allow such abortions throughout pregnancy . In the remaining cases, the upper time limit extends into the second trimester. Of the 191 laws reviewed, 188 allow abortion to preserve the woman's life. In Chile, El Salvador and Nicaragua, abortions are not permitted on any ground at any time during pregnancy .
|3. Abortion for health reasons|
Some 113 countries allow abortion to be performed on health grounds during the second trimester. Twenty-five of the 113 countries permit abortion only to save the life of the pregnant woman or to preserve her health. These include Algeria, Argentina, Burundi, Malaysia, Morocco, Pakistan, Peru and Rwanda.
|4. Abortion for fetal impairment|
The most common additional legal indication for second trimester abortion is fetal impairment or anomaly. This may reflect the growing sophistication and use of technology that can detect a genetic or physical abnormality, which is also increasingly available in developing countries. As with the health indication, interpretation of an indication of fetal impairment can pose difficulties. The most significant is a definition of what sort of fetal impairment is sufficiently serious to justify an abortion. This question has been addressed by some government ministries and medical professional associations. For example, in a position paper, the Netherlands Ministry of Health Welfare concluded that termination of pregnancy after 24 weeks was warranted in cases in which “the unborn child cannot reasonably be expected to survive outside the mother's body” or in which there are “fetal anomalies leading to serious and incurable functional disorders but which might reasonably be expected to have a chance of survival, although mostly a very limited one” . In a 2010 report, the UK's Royal College of Obstetricians & Gynaecologists (RCOG) advised that a number of factors be considered, including the potential for effective treatment; the probable degree of self-awareness on the part of the child and of the ability to communicate with others; the suffering that would be experienced; the probability of the child being able to live alone and to be self-supporting as an adult; and on the part of society, the extent to which actions performed by individuals without disability that are essential for health would have to be provided by others . The RCOG decided against specifying the types of fetal impairment that justify an abortion, and in fact almost no laws do so, as is also the case with the health indication.
|5. Abortion for pregnancy resulting from a sex offence|
The next most common indication for second trimester abortions, after life, health, and fetal impairment, is if the pregnancy resulted from a sex offence, most commonly rape, and in some but not all cases, incest. There are some 49 countries whose laws include this indication, approximately half of them developed countries. Almost 80% are the same countries that authorise abortion for fetal impairment, and almost all also permit abortions for health reasons. 57% of these countries set time limits on such abortions. These range from 16 weeks (four countries) to “viability” (two countries), with a lower average time limit than for abortions on health or fetal impairment grounds (see Table 1 - download full article ). The lower time limitmay reflect a belief that a woman (or girl) should be able to seek an abortion for a pregnancy resulting from a sex offence earlier than for other reasons. However, there is some evidence that women may be delayed in reporting rape and therefore in being able to seek an early abortion .
Anumber of these countries also requiremore than the woman's statement that the pregnancy resulted from a sexual offence. For example, in Bolivia a prosecution must have been initiated. In Cameroon, there must be a certificate from the prosecutor of a good case. In Hong Kong, the woman must make a report to a police officer. In Zimbabwe, a complaint must be lodged with the authorities. At least 12 countries require the approval of a committee or of two ormore physicians.
|6. Abortion on socio-economic grounds and/or on request|
Thirty-two countries allow second trimester abortions on broad socio-economic grounds. All of these countries also permit abortions for other reasons; 81% are developed countries or former Soviet republics or Soviet bloc countries that have long had liberal abortion laws. They include Great Britain, India, Japan, Russian Federation, South Africa and Ukraine. 69% set specific time limits for such abortions, ranging from 16 weeks (two countries) to 22 weeks (ten countries) to “viability” (two countries).
|7. Additional legal factors|
An analysis of the permitted indications and upper time limits for second trimester abortions tells only part of the story on the legal availability of the procedure. Many abortion laws establish additional conditions for carrying out abortions that can greatly affect access. One of these relates to who can perform abortions. Very few countries allow persons other than a physician to carry out a second trimester abortion, and some, such as Bulgaria, Greece, Libya, Madagascar, Seychelles and Turkey, mandate that the physician be an obstetrician/gynaecologist or have special training. However, this is now slowly changing for both first and second trimester medical abortions, with trained nurses, midwives and other mid-level providers able to manage these abortions alone . Moreover, many laws allow conscientious objection on the part of individual providers, although sometimes not if the life of the woman is at risk (e.g. Great Britain, Seychelles, Singapore and Zimbabwe).
Table 2 (download full article ) summarises changes in second trimester abortion laws that have occurred since 1990. At least 30 countries have significantly expanded indications for abortion , . These include Albania, Bhutan, Botswana, Cambodia, Colombia, Ethiopia, Fiji, Ghana, Guyana, Indonesia, Monaco, Nepal, Portugal, Saint Lucia, South Africa, Spain, Swaziland, Switzerland and Thailand. Five West African Francophone countries liberalised their abortion laws by means of comprehensive reproductive health legislation as well, and Kenya's new Constitution, approved by referendum in August 2010, allows abortion on grounds of life and health and leaves open the possibility that a law could subsequently be enacted that permits abortion on additional grounds. Almost all of these changes affect the legal status of second trimester abortions, whether by increasing indications for abortion without setting upper time limits, by endorsing specific indications for abortion with time limits, or both , . In addition, many countries have registered the use of mifepristone and/or misoprostol for inducing abortion, often only for the first nine weeks of pregnancy, ,  but off-label use in the second trimester is common, (Beverly Winikoff, Expanding access through off-label use of medical abortion, conference presentation, March 2010),  e.g. in Great Britain and the US, and across Scandinavia.
|9. Discussion and recommendations|
Key findings of this review are summarised in Box 1. Given that there are serious reasons why women have second trimester abortions, and that the laws in many countries do not make such abortions available, an important question to ask is how laws and regulations can be changed in order better to respond to women's
WHO's 2003 Safe Abortion: Technical and Policy Guidance for Health Systems contains a detailed analysis of access barriers and recommendations for their removal . For example, it proposes reducing or eliminating administrative and regulatory barriers in areas such as physician or committee authorisation, restrictive time limits, waiting periods, spousal and parental approval, facility and physician-only requirements, fees, licensing, and the reporting of rape. The broader aim of this guidance and its technical and policy recommendations is to provide evidence-based recommendations for making all abortions safe.
While it may be politically unrealistic to expect most countries to decriminalise all abortions in the near future, especially in the second trimester, less comprehensive legislative and regulatory changes are possible. These include recommendations aimed at ensuring that abortions are carried out as early as possible in pregnancy, and improving women's access to safe abortions through the removal of clinically unnecessary legal and regulatory restrictions.
All countries should allow abortions to preserve the woman's life, for broad physical and mental health reasons, and in cases of rape, incest and fetal impairment throughout the first and second trimesters of pregnancy. Moreover, countries could amend requirements on facilities and providers so that they are evidencebased, reflect current best practice and aim only to protect the health of the woman. Best practice with regards to induced abortion has changed substantially in the past 20+ years, and laws and regulations need to have the flexibility built into them to respond to these changes, both on grounds of safety and to keep costs as low as possible for women and health systems. For example, nurses, midwives, and other mid-level providers with appropriate training could be authorized to manage both first and second trimester medical abortion in modest inpatient facilities with good referral links for emergency medical care for the very small proportion of women who may need it . In addition, there should be no requirement that a commission or more than one physician authorize any abortion.
Spousal approval should never be necessary. Serious consideration should also be given to removing requirements for parental approval for minors to obtain an abortion, particularly where rape and incest may have been involved. Moreover, there should be no requirement that rape be reported or investigated, or that a magistrate give approval for abortions performed on this ground. In general, laws and regulations should be based on scientific evidence, be clear and uniform, and facilitate access to legal abortions. This would signal a government's commitment to allowing legal abortions to be performed, and allow women, health service
Regulations should call for the expeditious referral of patients seeking abortions by health personnel to an abortion provider, and their expeditious treatment once they have been referred. There is a growing body of sentiment that health care professionals who assert a “conscientious objection” and their institutions still have a duty to ensure that their patients have access to abortion , , , . Furthermore, governments should oversee and monitor the implementation of conscientious objection clauses so that women can actually access the services they are legally entitled to receive.
Governments should create women-supportive services that ensure privacy, confidentiality and compassionate and non-judgmental treatment,taking into account the experiences and needs of adolescents, and young and poor women especially. They should ensure thatwomen, health personnel and the public in general are educated about the law and where to obtain safe abortion information and services. They should consider providing abortion services free of charge or ensuring that costs do not prevent any woman who needs an abortion from having one.
Training for health personnel in safe abortion procedures, including for second trimester abortions, and addressing the emotional needs of women seeking abortions through provision of accurate information, and unbiased counselling (if requested by the woman), should be a required part of pre-service training for physicians and nurses in any country where abortion is legal for at least one indication. Lastly, improving
The author would like to thank the International Consortium for Medical Abortion for their financial support for the research for this paper, which was commissioned by them.
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Legal indication for second trimester abortion, by country, 2010