Worldwide, only 10–15% of abortions are performed beyond 12 weeks of pregnancy. However, they represent two-thirds of serious abortion-related complications. Over the last two decades, both medical and surgical methods of abortion during this gestational age range have become increasingly safe and more accessible.[i] The provision of medical abortion in particular has increased accessibility by expanding where abortion can be offered, as well as the types of providers who can be involved in abortion care.
Although most women and girls seek abortion care early in pregnancy, there are groups of women and girls who need abortion care beyond 12 weeks. For example, some women and girls develop medical indications as the pregnancy advances; fetal abnormalities may be detected, which generally do not happen until the second trimester; and life circumstances may change. Women and girls who present for abortion beyond 12 weeks of pregnancy are generally representative of more marginalised populations: they are more likely to have faced financial or logistical barriers to receiving care, to be an adolescent, victim of violence, and/or have delayed detection of their pregnancy.[ii] Finally, where access to safe abortion services is limited, such as in restrictive settings, presentation at later gestational ages for abortion care is relatively common.
Legal restrictions that embody gestational age limits increase barriers to abortion care and result in higher proportions of self-induced abortions beyond 12 weeks. As most maternal deaths due to abortion are the result of unsafe abortions beyond 12 weeks, limits to access – legal or otherwise b – compromise progress towards preventing maternal deaths.
FIGO position on the issue
FIGO recognises the persistent need for induced abortion and post-abortion care beyond 12 weeks of pregnancy. Abortion care in this gestational age range should be accessible and facilitated for those who need it, including for post-abortion care or any treatment needed by women and girls who have attempted to self-induce an abortion.
Induced abortion and post-abortion care beyond 12 weeks of pregnancy are safe and effective procedures when performed using professionally acceptable methods (for example those in the World Health Organization recommendations[ii]) and incur less risk to the health of woman and girls than continuing a pregnancy to full term.
FIGO supports the decriminalisation of abortion, in particular the decriminalisation of self-induced abortion, even beyond 12 weeks. Access to and provision of post-abortion care according to professional standards is legitimate, necessary and does not implicate providers in prior illegality or misconduct.
Service providers and facility managers should follow the WHO recommendations for safe provision of abortion and post-abortion care,[ii] which include the use of mifepristone followed by repeated doses of misoprostol; misoprostol alone; or dilation and evacuation. Furthermore, FIGO endorses the WHO recommendation that dilation and curettage should be considered an obsolete method of uterine evacuation and should be replaced by the recommended methods. For cases where gestational age exceeds 20 weeks, fetal demise prior to use of medical methods should be considered according to WHO recommendations.
Abortion care beyond 12 weeks of pregnancy should include immediate access to and provision of contraceptive counselling and methods, for those who desire it, and referral if a chosen method is not available. Counselling for spacing for those seeking to become pregnant again, or referral for such counselling, should also be provided.
Women and girls who decide to self-induce an abortion beyond 12 weeks of pregnancy should receive accurate information about how to use abortifacient medicines, what to expect, and where and under what conditions to seek treatment from a health care provider. Those that seek treatment should be treated without delay, respectfully, privately and with provider-patient confidentiality, according to the bioethical principles of beneficence and non-maleficence.
In order to encourage and facilitate the improvement of access to abortion care beyond 12 weeks of pregnancy, FIGO will:
- encourage national societies and providers to facilitate access for women and girls seeking abortion to allow for care as early in pregnancy as possible, and as late in pregnancy as needed
- support and promote autonomy in women and girls’ decision-making related to their reproductive health
- promote professional commitment to the principles of autonomy and justice, which are the basis of non-judgemental care, or referral for women and girls requesting abortion beyond 12 weeks of pregnancy
- ensure and promote the protection of women and girls’ reproductive rights, particularly for the most marginalised populations
- support the design and expansion of health providers’ education and in-service training programmes on abortion, including management of complications and post-abortion care beyond 12 weeks of pregnancy
- support the design or expansion of health providers’ training to include contraceptive counselling, and pregnancy spacing as part of abortion training programmes
- facilitate training, including values-clarification and attitude-transformation workshops, to decrease stigmatisation of abortion and providers of abortion
- support and promote adequate equipping of health facilities and functioning referral systems
- promote access to safe abortion and post-abortion care through the support of practitioners, professional associations, and those advocating to Ministries of Health minimise to the view of eliminating medical and professional barriers that are in conflict with the states human rights obligations.
[i] World Health Organization (WHO). Medical management of abortion. 2018. www.who.int/reproductivehealth/publications/medical-management-abortion
[ii] WHO. Safe abortion: technical and policy guidance for health systems. Second edition. 2012. www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en