Get the facts: ‘late term’ abortions

The phrase ‘late term abortion’ has no accepted medical definition and is generally used to provoke an emotional response. Although individual interpretations of the phrase differ, in the context of the Queensland debate it appears to most often refer to abortion performed at 20 weeks gestation or greater.

Much of the commentary surrounding the bills introduced by Rob Pyne in 2016 focussed on ‘late term abortion’, claiming the numbers of these procedures will increase under decriminalisation, that abortion ‘up to birth’ would be readily available, and that there will be no regulation of such procedures if criminal abortion law is repealed.

Let’s stop for a moment here to recognise that only a small proportion of terminations are carried out at 20 weeks gestation or later, and that the vast majority at this gestation in Australia (and in fact every single one at this gestation here in Queensland) are performed in hospitals.

Let’s also remember that there are currently no legislated gestational limits for abortion in Queensland. Sections 224-226 of our 1899 Criminal Code – the statutes which make abortion a crime – do not mention any gestational limit at which abortion is lawful or unlawful; it is equally unlawful (according to these sections) at any gestation, and the Criminal Code is therefore not what prevents women seeking abortion into the second and third trimesters for healthy pregnancies, or what prevents doctors from providing these procedures.

Later gestation abortion rate

A report by the Australian Institute of Health and Welfare estimated in 2005 that 0.7% of all abortions nationally were performed at or over 20 weeks gestation [1]. Data from South Australia shows that in 2014, 2.3% of the state’s terminations were performed at or over 20 weeks gestation [2].

In the entire country only one private clinic exists which provides abortion between 20 and 24 weeks gestation. It is on the outskirts of Melbourne, in Victoria, and is run by Australia’s largest abortion provider Marie Stopes International (MSI), who have 17 clinics across five states and territories. In 2016 they told a Queensland Parliamentary Committee that:

Regarding services up to 24 weeks, the vast majority of abortions in Australia, including by MSI, are performed in the first trimester. In Victoria, MSI provide termination of pregnancy services up to 24 weeks gestation. It is the only Australian private provider of abortion after 20 weeks gestation. Termination or pregnancy procedures of 20- to 24-week gestations comprise 0.5 per cent of all the terminations MSI did in Australia in 2015. Almost half of the women accessing post 20-week terminations at MSI travel interstate to Victoria.

All other procedures at these gestations or above, anywhere in the country, are provided in public or private hospitals.

Children by Choice, Queensland’s only independent pro-choice pregnancy counselling and support service, reports providing over 100 referrals interstate for clients each year. Around half of these referrals are due to gestational access issues [3].

While no national data on abortion procedures exist, there is a Medicare item number available for use in second trimester terminations (beyond 13-14 weeks gestation), item 16525:

‘MANAGEMENT OF SECOND TRIMESTER LABOUR, with or without induction, for intrauterine fetal death, gross fetal abnormality or life threatening maternal disease.’

16525 is the item code attached to termination procedures carried out in private abortion clinics after 13 weeks gestation.

Data from the Medicare website indicates that from 2005 to 2015, there were 8154 rebates provided nationally under this item number: [4]

In all states except WA, the number of rebates provided for second trimester abortion procedures has fallen slightly over this time period – including Tasmania and Victoria, where abortion law reform has occurred during this timeframe.

While these statistics do not include procedures offered in public hospitals, given what we know about the low numbers of terminations which occur in hospitals, we believe that the Medicare statistics demonstrate the low level of demand for these services irrespective of the legal framework around abortion in each state.

It is often claimed by anti-abortion groups that the numbers of ‘late term abortions’ in Victoria has increased by ridiculous numbers since law reform occurred in 2008. The Medicare data above shows that in the private sector this is certainly not the case; figures supplied by the 2012 and 2013 Victoria’s Mothers, Babies and Children report released in 2016 provide additional proof that these claims are completely unsubstantiated [5].

Who has second trimester abortions?

Despite what your local anti-choice lobby group may claim, women who seek abortion into the second trimester aren’t doing so because they’ve changed their minds, or because they’ve known about the pregnancy for a long time but just haven’t bothered to make a decision yet.

Women accessing abortion services at MSI after 20 weeks have a range of individual complex circumstances and different reasons for terminating pregnancy, with most women having multiple reasons for needing the service. Our patients’ reasons for accessing abortion services after 20 weeks include delayed pregnancy or diagnosis; mental health problems such as depression, anxiety and substance abuse; relationship breakdown and loss; family violence; sexual assault; foetal abnormality, often identified at around 20 weeks; lack of understanding of the Australian healthcare system; and barriers to accessing abortion care earlier in the pregnancy. As a provider of termination of pregnancy services up to 24 weeks gestation, MSI can attest to the need for specialised reproductive health services despite the small number of terminations occurring post 24 weeks.

– Alexis Apostolellis, CEO, Marie Stopes International Australia.

 

Children by Choice report that of their contacts with women more than 16 weeks pregnant, over 60% report domestic and/or sexual violence or a fetal anomaly diagnosis. In addition, women living in poverty are more likely to seek access to an abortion later in pregnancy. This can be because they are trying to gather money for the procedure, unaware that prices rise steeply after the 11 or 12 week mark.

But what about that whole abortion-up-to-birth thing?

Let’s let the experts answer that, shall we?

Third-trimester abortion is virtually unknown in Australia.

– Dr Caroline de Costa, Professor of Obstetrics and Gynaecology, James Cook University, 2016, at a Queensland parliamentary committee hearing.

I think you should understand that most pregnancy terminations are done in the first trimester, up to 14 weeks, and most of those are for psychological reasons. I do not know that psychological reasons would ever be the reason a late-term abortion would be performed. Then it is performed by serious foetal abnormalities which are often incompatible with life or for serious maternal illness. It is a different kettle of fish we are talking about. It is not a woman who wakes up one morning at 33 weeks and thinks, ‘I’ve had enough of this. I want it terminated.’ That never happens.

– Dr Paul Hyland, O&G, 2016, at a Queensland parliamentary committee hearing.

As far as we are aware the situation you spoke of, a woman flippantly deciding that because of financial reasons she not going to continue with a 32-week pregnancy, just does not exist. It is reassuring for humanity that women just do not do that. It just does not happen. Women just do not go in and flippantly want to end a 32-week pregnancy. I have been doing obstetrics for 33 years and I have never seen that. It just does not happen. It is only women in absolutely desperate circumstances who seek late termination of pregnancy. If there were an extraordinary one in 10 million who decided for whatever reason they were going to do that, they would never find a provider to perform such a termination of pregnancy. Although theoretically you can create all sorts of concoctions of what could happen and what might happen, the reality is that women never request it in such a circumstance and no provider would ever provide it in such a circumstance.

– Dr Michael Permezel, President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2016, at a Queensland parliamentary committee hearing.

The anti-abortion lobby place great store on late-term abortions. It is good publicity for their cause. Late-term abortions are traumatic, they are confronting and they are emotive. What you must realise is that … [it] is a rarity, it is done by expert doctors in big hospitals with plenty of experience and you really have to disregard the big fuss, I think, that is made about it on emotional grounds by those who oppose it.

– Dr Michael Carette, O&G, 2016, at a Queensland parliamentary committee hearing.

 

References:

[1] N Grayson, J Hargreaves & EA Sullivan 2005 Use of routinely collected national data sets for reporting on induced abortion in Australia. AIHW Cat. No. PER 30. Sydney: AIHW National Perinatal Statistics Unit (Perinatal Statistics Series No. 17). Online at http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442458945.

[2]W Scheil, K Jolly, J Scott, B Catcheside, L Sage, R Kennare Pregnancy Outcome in South Australia 2014. Adelaide: Pregnancy Outcome Unit, SA Health, Government of South Australia, 2016. Online at http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/health+statistics/pregnancy+outcome+statistics.

[3] Children by Choice submission to the Queensland Parliamentary Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee on the Abortion Law Reform (Women’s Right to Choose) Amendment Bill: June 2016; pg 38. Online at https://www.childrenbychoice.org.au/factsandfigures.

[4] Data extracted from the website of the Department of Human Services at http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp; search results as reported on http://medicarestatistics.humanservices.gov.au/statistics/do.jsp?_PROGRAM=%2Fstatistics%2Fmbs_item_standard_report&DRILL=ag&group=16525&VAR=services&STAT=count&RPT_FMT=by+time+period+and+state&PTYPE=calyear&START_DT=200501&END_DT=201512

[5] The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (2016) 2012 and 2013 Victoria’s Mothers, Babies and Children (Section 2: Data, tables and figures)  p 196; Department of Health and Human Services, Victorian Government, Melbourne; May 2016.

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