Second trimester Second trimester abortion in Europeabortion in Europe

Marge BererMarge BererEditor, Reproductive Health MattersEditor, Reproductive Health Matters

****************************

Chair, International Consortium for Medical AbortionChair, International Consortium for Medical Abortion

Why focus on second trimester abortions?Why focus on second trimester abortions?

Almost no one except the most dedicated providers do them.

The women who need them are often the most vulnerable.

They are currently the subject of anti-abortion attacks that seek to stigmatise them and separate them from first trimester abortions as being more “wrong”.(Britain, Spain, Netherlands, Russia, USA)

Almost no one except the most dedicated Almost no one except the most dedicated providers do them.providers do them.

The women who need them are The women who need them are often the often the most vulnerable.most vulnerable.

They are currently the subject of antiThey are currently the subject of anti--abortion attacks that seek to stigmatise abortion attacks that seek to stigmatise them and separate them from first trimester them and separate them from first trimester abortions as being more abortions as being more ““wrongwrong””..(Britain, Spain, Netherlands, Russia, USA)(Britain, Spain, Netherlands, Russia, USA)

How many women have them?How many women have them?

Britain 2007*▫

13-19 weeks

(17,430)

8.8%

▫

>20 weeks

(2,927)

1.5%

Netherlands 2006*▫

>12 weeks (4,508)

6.6%

South Africa 1997−2007▫

>12 weeks 33% +

▫

now 20%

*Includes women from abroad.(Ingham et al, Loeber & Wijsen, Barometer 2008)

Britain 2007*Britain 2007*▫▫

1313--19 weeks19 weeks

(17,430)(17,430)

8.8%8.8%

▫▫

>20 weeks>20 weeks

(2,927)(2,927)

1.5%1.5%

Netherlands 2006*▫

>12 weeks (4,508)

6.6%

South Africa 1997−2007▫

>12 weeks 33% +

▫

now 20%

*Includes women from abroad.(Ingham et al, Loeber & Wijsen, Barometer 2008)

Reasons: BritainReasons: Britain

Five stages of delay: ▫

suspecting pregnancy (21-79 days),

▫

confirming pregnancy (2-24 days),

▫

deciding on abortion (0-21 days),

▫

seeking abortion (0-7 days),

▫

obtaining abortion (7-21 days).

Factors − using contraception, bleeding continuing, changes in personal circumstances, fear of reaction of others, denial.

(Ingham et al 2008)

Five stages of delay: Five stages of delay: ▫▫

suspecting pregnancy (21suspecting pregnancy (21--79 days), 79 days),

▫▫

confirming pregnancy (2confirming pregnancy (2--24 days), 24 days),

▫▫

deciding on abortion (0deciding on abortion (0--21 days), 21 days),

▫▫

seeking abortion (0seeking abortion (0--7 days), 7 days),

▫▫

obtaining abortion (7obtaining abortion (7--21 days). 21 days).

Factors Factors −− using contraception, using contraception, bleeding continuing, changes in personal circumstances, , fear of reaction of others, denial.fear of reaction of others, denial.

(Ingham et al 2008)(Ingham et al 2008)

Reasons: NetherlandsReasons: Netherlands

Relationship problems (no partner, partner left, partner aggressive), young age (pregnancy too early), inability to recognise pregnancy, ambivalence towards the pregnancy, having to travel to the Netherlands for abortion and to a lesser extent being an immigrant from certain countries.

Early medical abortion does not appear to have an influence on the number of second trimester abortions in the Netherlands.

(Loeber & Wijsen 2008)

Relationship problems (no partner, partner left, Relationship problems (no partner, partner left, partner aggressive), partner aggressive), young age (pregnancy too early), inability to recognise pregnancy, ambivalence towards the pregnancy, having to travel to the Netherlands for abortion and to a lesser extent being an immigrant from certain countries.

Early medical abortion does not appear to have an influence on the number of second trimester abortions in the Netherlands.

(Loeber & Wijsen 2008)

Fetal anomaliesFetal anomalies

Wanted pregnancies.

Screening is or is becoming universal for all pregnancies, not just women over 35.

More anomalies detected.

Potentially more second trimester abortions.

Anti-abortionists also attacking these abortions as anti-disability rights and seeking to separate serious and what they consider not-so-serious anomalies.

Wanted pregnancies.Wanted pregnancies.

Screening is or is becoming universal for all Screening is or is becoming universal for all pregnancies, not just women over 35.pregnancies, not just women over 35.

More anomalies detected.More anomalies detected.

Potentially more second trimester abortions.Potentially more second trimester abortions.

AntiAnti--abortionists also attacking these abortionists also attacking these abortions as antiabortions as anti--disability rights and disability rights and seeking to separate serious and what they seeking to separate serious and what they consider notconsider not--soso--serious anomalies.serious anomalies.

ServiceService--related delaysrelated delays

Problem finding a doctor.

Doctor refuses to provide or refer.

Waiting list.

Difficulty finding the money.

Having to travel to another country in Europe.

Eliminating these delays would make some abortions earlier.

Women-related delays more difficult to address −

require education and support.

Problem finding a doctor.Problem finding a doctor.

Doctor refuses to provide or refer.Doctor refuses to provide or refer.

Waiting list.Waiting list.

Difficulty finding the money.Difficulty finding the money.

Having to travel to another country in Europe.Having to travel to another country in Europe.

Eliminating these delays would make some Eliminating these delays would make some abortions earlier. abortions earlier.

WomenWomen--related delays more difficult to related delays more difficult to address address −−

require education and support.require education and support.

Abortion Abortion ““tourismtourism””

Europe is not a community or a union when it comes to abortion law, especially as regards second trimester abortion.

Differences in the laws create problems for women and providers, especially after 20 weeks of pregnancy.

Internet purchase of medical abortion pills not recommended for second trimester.

Europe is not a community or a union Europe is not a community or a union when it comes to abortion law, especially when it comes to abortion law, especially as regards second trimester abortion.as regards second trimester abortion.

Differences in the laws create problems Differences in the laws create problems for women for women andand providers, especially after providers, especially after 20 weeks of pregnancy.20 weeks of pregnancy.

Internet purchase of medical abortion Internet purchase of medical abortion pills not recommended for second pills not recommended for second trimester. trimester.

Abortion Abortion ““tourismtourism””

All women travel.

Women over 12-14 weeks travel.

Women over 18-20 weeks travel.

Women over 24 weeks travel.

All women travel.All women travel.

Women over 12Women over 12--14 weeks travel.14 weeks travel.

Women over 18Women over 18--20 weeks travel. 20 weeks travel.

Women over 24 weeks travel.Women over 24 weeks travel.

Consequences of abortion tourismConsequences of abortion tourism

Second trimester abortions are not a public health problem, at least in western Europe (Russia), in spite of their illegality, because women travel to other countries for them.

The problems for women engendered by legal restrictions on second trimester abortion are in large part hidden by abortion “tourism”.

Second trimester abortions are not a Second trimester abortions are not a public health problem, at least in western public health problem, at least in western Europe Europe (Russia)(Russia), in spite of their illegality, , in spite of their illegality, because women travel to other countries because women travel to other countries for them.for them.

The problems for women engendered by The problems for women engendered by legal restrictions on second trimester legal restrictions on second trimester abortion are in large part hidden by abortion are in large part hidden by abortion abortion ““tourismtourism””..

Russia: what are women doing?Russia: what are women doing?Many second trimester abortions are unsafe in spite of a liberal law until 2003. A 1999 study found that only 6.6% of abortions took place at 13−27 weeks, but 76% of abortion-related deaths were associated with these abortions, inside + outside medical institutions.

Improving access, preventing delays and better treatment of complications were the key recommended strategies. Instead, in 2003, Russia restricted the legal grounds for abortions at 13–22 weeks from 12 to 4.

(Zhirova et al, 2004; CRR 2007)

Many second trimester abortions are unsafe in spite of a liberal law until 2003. A 1999 study found that only 6.6% of abortions took place at 13−27 weeks, but 76% of abortion-related deaths were associated with these abortions, inside + outside medical institutions.

Improving access, preventing delays and better treatment of complications were the key recommended strategies. Instead, in 2003, Russia restricted the legal grounds for abortions at 13–22 weeks from 12 to 4.

(Zhirova et al, 2004; CRR 2007)

Travelling from and toTravelling from and to……

Women currently travel from:Ireland, Northern Ireland, Portugal, Luxemburg, Belgium, France, Germany, Italy, Poland, Malta, Andorra, Monaco and even Britain

Women currently travel to:Spain, Netherlands, Britain

Women currently travel from:Women currently travel from:Ireland, Northern Ireland, Portugal, Ireland, Northern Ireland, Portugal, Luxemburg, Belgium, France, Germany, Luxemburg, Belgium, France, Germany, Italy, Poland, Malta, Andorra, Monaco and Italy, Poland, Malta, Andorra, Monaco and even Britaineven Britain

Women currently travel to:Women currently travel to:Spain, Netherlands, BritainSpain, Netherlands, Britain

Where Polish women are goingWhere Polish women are going

Clandestine providers at home.

Germany, Czech Republic, Austria, Netherlands

Probably also other Eastern European countries (Ukraine, Belarus, Lithuania) but mainly those who live close by and have connections there.

(Wanda Nowicka)

Clandestine providers at home.Clandestine providers at home.

Germany, Czech Republic, Austria, Germany, Czech Republic, Austria, Netherlands Netherlands

Probably also other Eastern European Probably also other Eastern European countries (Ukraine, Belarus, Lithuania) countries (Ukraine, Belarus, Lithuania) but mainly those who live close by and but mainly those who live close by and have connections there. have connections there.

(Wanda Nowicka)(Wanda Nowicka)

AllAll--European hypocrisyEuropean hypocrisyIn most European countries, the state recognises that it has a duty of care to keep abortions legal and safe.

Remaining countries and those with restrictions in the second trimester count on others to take care of their “problem” for them. However, these are not cross-country agreements, but a result of the reneging of responsibility. Sweden’s recent decision to allow women to come there for abortions is an exception.

Continuing stigma in second trimester = at risk legally, open to anti-abortion attack.

In most European countries, the state recognises In most European countries, the state recognises that it has a duty of care to keep abortions legal that it has a duty of care to keep abortions legal and safe.and safe.

Remaining countries and those with restrictions Remaining countries and those with restrictions in the second trimester count on others to take in the second trimester count on others to take care of their care of their ““problemproblem”” for them. However, these for them. However, these are not crossare not cross--country agreements, but a result of country agreements, but a result of the reneging of responsibility. Swedenthe reneging of responsibility. Sweden’’s recent s recent decision to allow women to come there for decision to allow women to come there for abortions is an exception. abortions is an exception.

Continuing stigma in second trimester = Continuing stigma in second trimester = at risk legally, open to antiat risk legally, open to anti--abortion attack. abortion attack.

Right to travel protectedRight to travel protected

Harmonisation of EC law – suggestions rejected in previous decades.

Two European court rulings in Irish cases:

▫

Grogan –

right to travel to obtain a legal (medical) service.

(Euro Court of Justice, 1989)

▫

Open Door Counselling/Dublin Well Woman – right to freedom of information.

(Euro Court of

Human Rights, 1992) (Fletcher, RHM 2000)

Harmonisation of EC law Harmonisation of EC law –– suggestions suggestions rejected in previous decades.rejected in previous decades.

Two European court rulings in Irish cases:Two European court rulings in Irish cases:

▫▫

Grogan Grogan ––

right to travel to obtain a legal right to travel to obtain a legal (medical) service.(medical) service.

(Euro Court of Justice, 1989) (Euro Court of Justice, 1989)

▫▫

Open Door Counselling/Dublin Well Woman Open Door Counselling/Dublin Well Woman –– right to freedom of information.right to freedom of information.

(Euro Court of (Euro Court of

Human Rights, 1992)Human Rights, 1992)(Fletcher, RHM 2000)(Fletcher, RHM 2000)

The most vulnerable abortionsThe most vulnerable abortions

‘‘Although abortion after 24 weeks should be necessary only on the rare occasions when a fetal abnormality has not been discovered earlier in pregnancy, it should be regarded as ethical regardless of its timing.’’ (David Paintin, BJOG 1997) British law has been in line with this view since 1990.

Only Britain and Spain allow abortions after 24 weeks, but there are British women who have to go to Spain.

‘‘‘‘Although abortion after 24 weeks should Although abortion after 24 weeks should be necessary only on the rare occasions be necessary only on the rare occasions when a fetal abnormality has not been when a fetal abnormality has not been discovered earlier in pregnancy, it should discovered earlier in pregnancy, it should be regarded as ethical regardless of its be regarded as ethical regardless of its timing.timing.’’’’ (David Paintin, BJOG 1997) (David Paintin, BJOG 1997) British law has British law has been in line with this view since 1990.been in line with this view since 1990.

Only Britain and Spain allow abortions Only Britain and Spain allow abortions after 24 weeks, but there are British after 24 weeks, but there are British women who have to go to Spain.women who have to go to Spain.

History of travelling since 1950sHistory of travelling since 1950s

Women travelling from one European country to another for abortion has been going on since eastern European countries followed the Soviet Union in legalising abortion in the 1950s.

At that time, western European women went to Poland and Yugoslavia for abortions.

Women travelling from one European Women travelling from one European country to another for abortion has been country to another for abortion has been going on since eastern European going on since eastern European countries followed the Soviet Union in countries followed the Soviet Union in legalising abortion in the 1950s.legalising abortion in the 1950s.

At that time, western European women At that time, western European women went to Poland and Yugoslavia for went to Poland and Yugoslavia for abortions. abortions.

HistoryHistory…… continued continued

In 1975, about 90% of the 100,000 abortions performed in Dutch clinics were women from abroad, mostly West Germans.

(Evert Ketting, personal communication, July 2008)

At least 130,500 Irish women have travelled to England and Wales to date to have abortions since 1968. (DoH 2006/2008)

In 1976, 30,000 Spanish women were travelling annually to Britain for safe abortions.

(El Pais, 1976)

In 1975, about 90% of the 100,000 abortions In 1975, about 90% of the 100,000 abortions performed in Dutch clinics were women from performed in Dutch clinics were women from abroad, mostly West Germans. abroad, mostly West Germans.

(Evert Ketting, personal communication, July 2008)(Evert Ketting, personal communication, July 2008)

At least 130,500 Irish women have travelled to At least 130,500 Irish women have travelled to England and Wales to date to have abortions England and Wales to date to have abortions since 1968. since 1968. (DoH 2006/2008)(DoH 2006/2008)

In 1976, 30,000 Spanish women were travelling In 1976, 30,000 Spanish women were travelling annually to Britain for safe abortions. annually to Britain for safe abortions.

(El Pais, 1976)(El Pais, 1976)

HistoryHistory…… continuedcontinued

Most European countries have made abortion legal and accessible in the first trimester.

The number of women travelling to Britain declined from 56,591 in 1973 to 9,833 in 2000.

The number travelling to the Netherlands also decreased, from 10,000 in 1990 to about 4,000 in 2004. (Gevers S, 2006)

We need to know what proportion of women who are currently travelling are doing so for second trimester procedures.

Most European countries have made abortion Most European countries have made abortion legal and accessible in the first trimester. legal and accessible in the first trimester.

The number of women travelling to Britain The number of women travelling to Britain declined from 56,591 in 1973 to 9,833 in 2000.declined from 56,591 in 1973 to 9,833 in 2000.

The number travelling to the Netherlands also The number travelling to the Netherlands also decreased, from 10,000 in 1990 to about 4,000 in decreased, from 10,000 in 1990 to about 4,000 in 2004.2004. (Gevers S, 2006)(Gevers S, 2006)

We need to know what proportion of women We need to know what proportion of women who are currently travelling are doing so for who are currently travelling are doing so for second trimester procedures.second trimester procedures.

RecommendationsRecommendationsIn-depth, country-based studies on 2nd trimester abortions − reasons, women, gestation, provider, method, delays.

Inter-country travel − reasons, who, from/to where, gestation, provider involvement at both ends, cost, delays.

Referral agreements − all-European?

Network for second trimester providers to help reduce isolation, and foster solidarity.

InIn--depth, countrydepth, country--based studies on 2nd based studies on 2nd trimester abortions trimester abortions −− reasons, women, reasons, women, gestation, provider, method, delays.gestation, provider, method, delays.

InterInter--country travel country travel −− reasons, who, from/to reasons, who, from/to where, gestation, provider involvement at where, gestation, provider involvement at both ends, cost, delays.both ends, cost, delays.

Referral agreements Referral agreements −− allall--European?European?

Network for second trimester providers to Network for second trimester providers to help reduce isolation, and foster help reduce isolation, and foster solidarity.solidarity.

Proposal to FIAPACProposal to FIAPAC

With these data, organise an all-European meeting of representatives from Health Departments, national policymakers, abortion rights advocates and service providers to discuss abortion tourism and develop viable proposals on what to do about it, with a view if possible to relegating the need for it to history, even if harmonisation of Europe’s abortion laws is not possible or indeed desirable.

With these data, organise an allWith these data, organise an all--European European meeting of representatives from Health meeting of representatives from Health Departments, national policymakers, Departments, national policymakers, abortion rights advocates and service abortion rights advocates and service providers to discuss abortion tourism and providers to discuss abortion tourism and develop viable proposals on what to do develop viable proposals on what to do about it, with a view if possible to relegating about it, with a view if possible to relegating the need for it to history, even if the need for it to history, even if harmonisation of Europeharmonisation of Europe’’s abortion laws is s abortion laws is not possible or indeed desirable. not possible or indeed desirable.

RHM publicationRHM publication

Second trimester abortion: public policy and women’s health

<www.rhmjournal.org.uk>*****

<www.rhm-elsevier.com>

Second trimester abortion: Second trimester abortion: public policy and womenpublic policy and women’’s healths health

<www.rhmjournal.org.uk><www.rhmjournal.org.uk>**********

<www.rhm<www.rhm--elsevier.com>elsevier.com>