Last reviewed: February 7, 2021
Key Information:
- Women who present for abortion at 13 weeks of pregnancy or later are more likely than those who present at earlier gestations to be young or a victim of violence, have detected their pregnancy later, feel ambivalent about the abortion decision, and/or have financial and logistical barriers to care. Additionally, medical or fetal indications for an abortion may not be apparent until after 13 weeks. Reasons for presenting at or after 13 weeks gestation appear similar across countries and cultures and disproportionately affect underserved women.
Quality of evidence: Low
Epidemiology of abortion at 13 weeks and later
While abortions at or after 13 weeks gestation comprise a minority (around 10-15%) of the total abortions worldwide, they are responsible for the majority of serious abortion-related complications . In more restrictive settings, or where safe abortion access is limited, presentation at or after 13 weeks gestation for postabortion care is more common. In Cambodia 17%, in Ethiopia 38%, and in Kenya 41% of women needing postabortion care present at or after 13 weeks gestation. (African Population and Health Research Center, Ministry of Health Kenya, Ipas Kenya, & Guttmacher Institute, 2013; Fetters, Vonthanak, Picardo, & Rathavy, 2008; Gebreselassie et al., 2010).
Why do women need abortions at 13 weeks and later?
Young age: Young women are disproportionately likely to seek abortion at or after 13 weeks. In the United States, 23.7% of girls younger than age 15 and 12.4% of adolescents ages 15-19 seeking abortion care do so after 13 weeks gestation In Mexico City, adolescents comprised 9% of all women seeking abortion from 2007-2015; yet, they accounted for 13% of women seeking abortion beyond 12 weeks gestation (Saavedra-Avendano et al., 2018). Smaller case-control and cohort studies in Ethiopia, India, Nepal, Singapore and the United States have found young age to be a risk factor for later presentation (Bonnen, Tuijje, & Rasch, 2014; Foster & Kimport, 2013; Lim, Wong, Yong, & Singh, 2012; Sowmini, 2013).
Late detection of pregnancy: A common risk factor in all studies for presenting for abortion at or after 13 weeks is late recognition of pregnancy. Absence of pregnancy signs and symptoms, menstrual irregularity, contraceptive use, or amenorrhea after recent pregnancy can mask physical signs of pregnancy and delay pregnancy diagnosis (Constant, Kluge, Harries, & Grossman, 2019; Drey et al., 2006; Foster & Kimport, 2013; Gallo & Nghia, 2007; Harries, Orner, Gabriel, & Mitchell, 2007; Ingham, Lee, Clements, & Stone, 2008; Jones & Jerman, 2017; Purcell et al., 2014). In one case-control study in the United States, women who sought abortion after 20 weeks were much more likely to have been eight weeks pregnant or more at the time they discovered they were pregnant (68%), compared to women who had abortions before 13 weeks gestation (12%) (Foster & Kimport, 2013).
Ambivalence and/or difficulty with abortion decision: Women’s decisionmaking may be delayed due to social pressures, fears, religious attitudes and changes in relationship status. Changes in circumstance (such as abandonment by partner) cause some women to seek an abortion after initially planning to continue the pregnancy (Foster & Kimport, 2013; Gallo & Nghia, 2007; Harries et al., 2007). Discouraging family and friends may also delay a woman seeking care (Waddington, Hahn, & Reid, 2015).
Financial and logistical barriers: Unemployment and lack of health insurance are risk factors for presentation at 13 weeks or later, according to studies conducted in the United States (Gonzalez, Quast, & Venanzi, 2019; Raidoo, Tschann, Kaneshiro & Sentell, 2020). Globally, poverty (Usta, Mitchell, Gebreselassie, Brookman-Amissah, & Kwizera, 2008), immigrant status (Gonzalez-Rabago, Rodriguez-Alvarez, Borrell, & Martin, 2017; Loeber & Wijsen, 2008), rural residence (Bonnen et al., 2014; Ushie, Izugbara, Mutua, & Kabiru, 2018) and lack of employment (Van de Velde, Van Eekert, Van Assche, Sommerland, & Wouters, 2019) are additional risk factors. Delays may be related to raising enough money to cover the cost of the procedure, particularly as procedures later in gestation are more expensive (Foster & Kimport, 2013; Kiley, Yee, Niemi, Feinglass, & Simon, 2010). Abortions at or after 13 weeks gestation are provided at a limited number of facilities and travel logistics present difficulties for many. In one case-control study of women presenting for abortion at over 20 weeks gestation, women were much more likely than those in earlier gestations to have travelled over three hours to access care (Foster & Kimport, 2013). Clients at 13 weeks gestation or later may be referred by other providers or have trouble finding a provider before finally accessing care (Drey et al., 2006; Harries et al., 2007). Women may also need to travel out of their own country to access legal abortion after 13 weeks ( Cameron et al., 2016; Loeber & Wijsen, 2008).
Fetal indications: Prenatal diagnosis of fetal anomalies typically occurs after the first 12 weeks of pregnancy, and women may make the decision to terminate pregnancy based on the diagnosis (Lyus, Robson, Parsons, Fisher, & Cameron, 2013).
Maternal indications: A woman may have a medical condition that worsens through the course of pregnancy or a new condition may arise in pregnancy that endangers her life or health (Kiver, Altmann, Kamhieh-Milz, & Weichert, 2019). Severe preeclampsia or preterm premature rupture of membranes may require termination of pregnancy to save a woman’s life (American College of Obstetricians and Gynecologists, 2015).
Victims of violence: Victims of violence have a higher risk of late presentation (Colarossi & Dean, 2014; Perry et al., 2015).
Failed abortion: Although failures are rare, women who experience an ongoing pregnancy after an abortion before 13 weeks may not discover they are still pregnant until after 13 weeks gestation (Gallo & Nghia, 2007).
Cultural beliefs: In rare cases there are local beliefs that having an abortion at 13 weeks or later is safer than the first 12 weeks of pregnancy, thus causing women to delay care (Marlow et al., 2014).
References
African Population and Health Research Center, Ministry of Health Kenya, Ipas Kenya, & Guttmacher Institute. (2013). Incidence and complications of unsafe abortion in Kenya: Key findings of a national study. Retrieved from https://www.guttmacher.org/pubs/abortion-in-Kenya.pdf
American College of Obstetricians and Gynecologists. (2013, reaffirmed 2015). Practice Bulletin No. 135: Second-trimester abortion. Obstetrics & Gynecology, 121(6), 1394-1406.
Bonnen, K. I., Tuijje, D. N., & Rasch, V. (2014). Determinants of first and second trimester induced abortion – results from a cross-sectional study taken place 7 years after abortion law revisions in Ethiopia. BioMed Central Pregnancy & Childbirth, 14(416), 014-0416.
Cameron, S. T, Ridell, J., Brown, A., Thomson, A., Melville, C., Flett, G., … Laird, G. (2016). Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: National audit 2013-2014. European Journal of Contraception and Reproductive Health Care, 21(2), 183-188.
Colarossi, L., & Dean, G. (2014). Partner violence and abortion characteristics. Women Health, 54(3), 177-193.
Constant, D., Kluge, J., Harries, J., & Grossman, D. (2019). An analysis of delays among women accessing second-trimester abortion in the public sector in South Africa. Contraception, 100(3), 209-213.
Drey, E. A., Foster, D. G., Jackson, R. A., Lee, S. J., Cardenas, L. H., & Darney, P. D. (2006). Risk factors associated with presenting for abortion in the second trimester. Obstetrics and Gynecology, 107(1), 128-135.
Fetters, T., Vonthanak, S., Picardo, C., & Rathavy, T. (2008). Abortion‐related complications in Cambodia. BJOG: An International Journal of Obstetrics & Gynaecology, 115(8), 957-968.
Foster, D. G., & Kimport, K. (2013). Who seeks abortions at or after 20 weeks? Perspectives on Sexual and Reproductive Health, 45(4), 210-218.
Gallo, M. F., & Nghia, N. C. (2007). Real life is different: A qualitative study of why women delay abortion until the second trimester in Vietnam. Social Science & Medicine, 64(9), 1812-1822.
Gebreselassie, H., Fetters, T., Singh, S., Abdella, A., Gebrehiwot, Y., Tesfaye, S., & Kumbi, S. (2010). Caring for women with abortion complications in Ethiopia: National estimates and future implications. International Perspectives on Sexual and Reproductive Health, 36(1), 6-15.
Gonzalez-Rabago, Y., Rodriguez-Alvarez, E., Borrell, L. N., & Martin, U. (2017). The role of birthplace and educational attainment on induced abortion inequalities. BMC Public Health, 17, 69.
Gonzalez, F., Quast, T., & Venanzi, A. (2019). Factors associated with the timing of abortions. Health economics, 1-11.
Harries, J., Orner, P., Gabriel, M., & Mitchell, E. (2007). Delays in seeking an abortion until the second trimester: A qualitative study in South Africa. Reproductive Health, 4(7), 13-26.
Harris, L. H., & Grossman, D. (2011). Confronting the challenge of unsafe second-trimester abortion. International Journal of Gynecology & Obstetrics, 115(1), 77-79.
Ingham, R., Lee, E., Clements, S. J., & Stone, N. (2008). Reasons for second trimester abortions in England and Wales. Reproductive Health Matters, 16(31 Suppl), 18-29.
Jatloui, T. C., Eckhaus, L.., Mandel, M.G.,Nguyen, A., Pduyebo, T., Petersen, E., Whiteman, M.K. (2019). Abortion surveillance-United States, 2016. MMWR Surveillance Summaries, 68(11): 1-41.
Jones, R. K., & Jerman, J. (2017). Characteristics and circumstances of women who obtiain very early or second trimester abortions. PLoS ONE, DOI: 10.1371/journal.pone.0169969.
Kiley, J. W., Yee, L. M., Niemi, C. M., Feinglass, J. M., & Simon, M. A. (2010). Delays in request for pregnancy termination: Comparison of patients in the first and second trimesters. Contraception, 81(5), 446-451.
Kiver, V.I., Altmann, J., Kamhieh-Milz, J. & Weichert, A. (2019) A 17-year analysis of pregnancy termination ≥14 weeks of gestation in a German level 1 perinatal center. Journal of Perinatal Medicine, 47(8):847-856.
Lim, L., Wong, H., Yong, E., & Singh, K. (2012). Profiles of women presenting for abortions in Singapore: Focus on teenage abortions and late abortions. European Journal of Obstetrics & Gynecology and Reproductive Biology, 160(2), 219-222.
Loeber, O., & Wijsen, C. (2008). Factors influencing the percentage of second trimester abortions in the Netherlands. Reproductive Health Matters, 16(31 Suppl), 30-36.
Lyus, R., Robson, S., Parsons, J., Fisher, J., & Cameron, M. (2013). Second trimester abortion for fetal abnormality. BMJ: British Medical Journal, 3(347).
Marlow, H. M., Wamugi, S., Yegon, E., Fetters, T., Wanaswa, L., & Msipa-Ndebele, S. (2014). Women’s perceptions about abortion in their communities: Perspectives from western Kenya. Reproductive Health Matters, 22(43), 149-158.
Perry, R., Zimmerman, L., Al-Saden, I., Fatima, A., Cowett, A., & Patel, A. (2015). Prevalence of rape-related pregnancy as an indication for abortion at two urban family planning clinics. Contraception, 91(5), 393-397.
Purcell, C., Cameron, S., Caird, L., Flett, G., Laird, G., Melville, C., & McDaid, L. M. (2014). Access to and experience of later abortion: Accounts from women in Scotland. Perspectives on Sexual and Reproductive Health, 46(2), 101-108.
Raidoo, S., Tschann, M., Kaneshiro, B. & Sentell, T. (2020). Impact of insurance coverage for abortion in Hawai’i on gestational age at presentation and trype of abortion, 2010-2013. Hawaii Journal of Health & Social Welfare, 79(4):117-122.
Saavedra-Avendano, B., Schiavon, R., Sanhueza, P., Rios-Polanco, R., Garcia-Martinez, L., & Darney, B. G. (2018). Who presents past the gestational age limit for first trimester abortion in the public sector in Mexico City? PLoS One, 13(2), e0192547.
Sowmini, C. V. (2013). Delay in termination of pregnancy among unmarried adolescents and young women attending a tertiary hospital abortion clinic in Trivandrum, Kerala, India. Reproductive Health Matters, 21(41), 243-250. DOI: 10.1016/s0968-8080(13)41700-7
Ushie, B. A., Izugbara, C. O., Mutua, M. M., & Kabiru, C. W. (2018). Timing of abortion among adolescent and young women presenting for post-abortion care in Kenya: A cross-sectional analysis of nationally-representative data. BMC Womens Health, 18(1), 41.
Usta, M. B., Mitchell, E. M., Gebreselassie, H., Brookman-Amissah, E., & Kwizera, A. (2008). Who is excluded when abortion access is restricted to twelve weeks? Evidence from Maputo, Mozambique. Reproductive Health Matters, 16(31 Suppl), 14-17.
Van de Velde, S., Van Eekert, N., Van Assche, K., Sommerland, N., & Wouters, E. (2019) Characteristics of women who present for abortion beyond the legal limit in Flanders, Belgium. Perspectives in Sexual Reproductive Health, 51(3):175-183.
Waddington, A., Hahn, P. M., & Reid, R. (2015). Determinants of late presentation for induced abortion care. Journal of Obstetrics and Gynaecology Canada, 37(1), 40-45.
