https://orcid.org/0000-0002-0996-7408
Figures
Abstract
Understanding the circumstances of abortions later in pregnancy provides insight about the barriers and delays to timely care. Limited synthesized information is available on these circumstances, especially from low and middle incomes countries. Reviewing what is reported in the literature about the circumstances of abortion later in pregnancy and the methodological approaches used to study this is needed to reveal evidence gaps. The purpose of this study is to describe what is documented and methodological approaches used in existing literature on the circumstances and characteristics associated with seeking care for abortion later in pregnancy reported in population and facility-based studies. We conducted a scoping review of peer-reviewed research in OVID/PubMed, Embase, Scopus, SocIndex, and LILACs from 2007–2024 that described the circumstance, sociodemographic characteristics, population- or facility-based proportion of abortion later in pregnancy (≥12 weeks of gestation or “second trimester”) reported in the literature. We screened 2598 records by title and/or abstract and 668 of those by full text. We included 78 studies that described the circumstances around seeking care for abortion later in pregnancy from qualitative data (12 studies); included information on associated characteristics from quantitative data (15 studies); reported a population- (17 studies) or facility-based (45 studies) proportion of abortion later in pregnancy. Prominent themes included health system challenges, late pregnancy recognition, financial challenges, and delayed decision making. Low economic status and adolescence were commonly associated characteristics. Population and facility-based studies lacked standardization when reporting durations of gestation. Facility studies reported a wide variety of populations and number of facilities. Circumstances surrounding abortions later in pregnancy include health system challenges, late pregnancy recognition, financial issues, and delayed decision-making, which intersect to compound and extend delays. More research guided by clear methods and standard definitions when reporting on population and facility-based proportions of abortions later in pregnancy is needed to reveal evidence gaps and better inform policies and programs.
Citation: Jacobson LE, Darney BG, Johnston HB, Ganatra B (2024) A global scoping review of the circumstances of care seeking for abortion later in pregnancy. PLOS Glob Public Health 4(12): e0003965. https://doi.org/10.1371/journal.pgph.0003965
Editor: Camila Gianella Malca, Pontifical Catholic University of Peru: Pontificia Universidad Catolica del Peru, PERU
Received: May 16, 2024; Accepted: October 30, 2024; Published: December 5, 2024
Copyright: © 2024 Jacobson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data are publicly available, published manuscripts.
Funding: This work was supported by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO) (to author BG). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of, and should not be attributed to, the World Health Organization.
Competing interests: LEJ has nothing to disclose. BGD is a member of the Board of Directors of the Society of Family Planning (SFP) and CISIDAT (Health Research Consortium, Mexico). She is a Deputy Editor at Contraception and a committee member at the American College of Obstetrics and Gynecology (ACOG), activities for which she receives honoraria. She is also supported by a Garcia-Robles COMEXUS-Fulbright award, Mexico, 2023-2024. HBJ has nothing to disclose. BG has nothing to disclose.
Background
Abortion is an essential sexual and reproductive health care service. Globally, induced abortion is common: an estimated 73.3 million abortions occur annually worldwide both in settings where abortion law is liberal and where it is restrictive [1]. Legal restrictions to abortion reduce access to safe abortion care [2]. Abortion can be safely provided throughout pregnancy [3], although the provision of both medical and surgical abortion is simpler in early pregnancy. In high income countries, over 90% of all abortions occur before 13 weeks of gestation, and more than two-thirds of abortions occur before nine weeks of gestation [4]. Abortion is necessary later in pregnancy due to delayed pregnancy recognition, delays in access to care due stigma and logistics, and receiving new medical information [5, 6]. Known barriers to accessing abortion care later in pregnancy include limited availability of trained providers and facilities authorized to provide services, high costs, abortion-related stigma, and legal restrictions [7–9]. However, there is limited synthesized information available on the circumstances of those seeking abortion later in pregnancy, especially from low and middle incomes countries.
The purpose of this scoping review was to describe the circumstances associated with seeking care for abortion later in pregnancy and how abortions later in pregnancy are reported in the literature. These questions are important to provide insights into the complex factors correlated with seeking care for abortion later in pregnancy and to identify gaps in the current state of reporting and documentation of abortion. This knowledge can inform healthcare professionals, policymakers, and researchers as they develop evidence-based interventions to improve the accessibility and quality of reproductive healthcare services. To address the knowledge gap, we conducted a scoping review to identify what is reported in the literature about the circumstances of abortion later in pregnancy (≥12 weeks of gestation or labeled as “second trimester”), the methodological approaches used to study and report this, and key evidence gaps to be addressed in future research.
Methods
We conducted a scoping review informed by Arksey & O’Malley [10]. We described the circumstances of an abortion later in pregnancy, meaning the contextual factors involved in or reasons for needing abortion later in pregnancy as well as individual sociodemographic or other characteristics. We anticipated finding varied types of evidence from diverse study designs and our interest was in documenting this variability. We also summarized available reports of the proportion of abortions later in pregnancy (≥12 weeks of gestation or labeled as “second trimester”) from both population- and facility-based studies. We conducted this review following PRISMA-ScR guidelines [11].
Author LJ collaborated with an academic public health librarian to design and run the database search using five bibliographic databases: Scopus, Ovid/PubMed, Embase, SocIndex, and LILACs to identify articles published between January 2007-April 2024. The scoping review considered publications reporting quantitative and qualitative analyses on incidence of experience of induced abortion, denial of abortion, and/or post-abortion care for complication after induced abortion later in pregnancy from any country that were published in peer-reviewed and grey literature. Each search was customized for the database and sought to capture two main concepts: 1. circumstances surrounding seeking care for abortion later in pregnancy and 2. proportion of abortions reported from population or facility-data occurring later in pregnancy. The major search concepts are displayed in Table 1 and the bibliographic database search strategy for OVID/PubMed can be found in S1 Table, all other search strategies contained the same terms.
We added grey literature sources from scanning websites of research and non-governmental organizations that conduct abortion research (see full list in S2 Table) and additional hand selected articles from manual review of journals or reference lists of screened articles.
There is a lack of shared definitions and terminology regarding abortion at different stages in pregnancy [12]. This scoping review focuses on abortion later in pregnancy which we define as ≥12 weeks of gestation or labeled “second trimester”. We also included studies of abortions at gestational legal limits that did not explicitly state weeks of gestation. We chose abortion later in pregnancy and gestational legal limits because most abortions occur early in pregnancy [13] and we wanted to capture circumstance of abortion at stages of abortion known to be associated with greater structural barriers and care seeking delays.
We included articles published in English, Spanish, French, and Portuguese that included description of the circumstance and/or socio-demographic or other characteristics of seeking or obtaining an induced abortion later in pregnancy and/or studies that reported the proportion of abortion occurring later in pregnancy. We also included studies on people who received care for complications following an induced abortion or denied an abortion later in pregnancy if circumstances for seeking an abortion were described.
We excluded studies that were narrative reviews; editorial articles; and randomized controlled trial or clinical intervention when the research design depends on a priori sample sizes for groups. Additionally, we excluded studies that were solely focused on spontaneous abortion and those that did not distinguish between induced and spontaneous abortion. We excluded studies that included only abortion for non-viable pregnancies or congenital anomalies. We chose to exclude these studies because abortion for congenital anomalies is well documented in the literature, more clearly understood, and less stigmatized than other circumstances [6, 14–16]. We also excluded conference abstracts because they are often preliminary, incomplete, or lack sufficient detail needed. See the population, intervention, control, outcome, timeframe, setting (PICOTS) criteria used in the scoping review in Table 2.
Author LJ conducted the title/abstract screen, full text review, and completed data extraction. LJ captured data on a standardized extraction form in Excel to collect information on country; study setting; data type; data year(s); sample size; weeks of gestation cutoff or range reported (at least ≥12 weeks when weeks of gestation were listed); proportion reported of abortion ≥12 weeks or labeled as second trimester; circumstance of a later abortion; associated socio-demographic characteristics; and any relevant limitations of the study. Studies were further categorized by use of qualitative data representing client accounts and use of quantitative data that describe sociodemographic or other characteristics associated with abortion later in pregnancy. To analyze the themes surrounding the circumstances from qualitative studies, we used a thematic analysis technique [17] to capture common themes that emerged. Data extraction and categorization of themes were conducted in the Excel form. An aim in this scoping review was to maximize the breadth of included studies. We did not assess the methodological quality of included studies.
Results
The database searched yielded 2893 records after duplicates were removed (Fig 1).
*Note that studies included do not add up to 78 because some had more than one type of included information (qualitative data on circumstances, sociodemographic or other characteristics, population, or facility-based proportion of abortion later in pregnancy).
We added 64 records from grey literature and removed 359 conference abstracts then screened 2598 records by title and/or abstract and of those included 735 records for full text review. Reasons articles were excluded upon full-text review include additional duplicates; duplicate data points; and the sample not meeting inclusion criteria (e.g., spontaneous abortion, non-viable pregnancy). We included a total of 78 studies. Of the included studies, 12 described the circumstances around seeking care for abortion later in pregnancy using qualitative data; 15 included quantitative data on sociodemographic or other characteristics associated with abortion later in pregnancy. Seventeen studies reported a population-based proportion of abortion later in pregnancy; and 45 reported a facility-based proportion of abortion later in pregnancy. Twelve studies included more than one type of key information. Results represented 30 countries. Details of included study characteristics are shown in Table 3.
Circumstances of and sociodemographic characteristics associated with seeking care for abortion later in pregnancy
We identified 12 studies that described the circumstance around seeking care for abortion later in pregnancy from qualitative interviews and 15 studies that included quantitative information on sociodemographic or other characteristics associated with abortion later in pregnancy.
From the 12 studies that reported qualitative data, we identified four main themes of circumstance of seeking an abortion later in pregnancy that occurred most frequently: health system challenges (12 studies), late pregnancy recognition (10 studies), financial challenges (8 studies), and delayed decision making (7 studies). These main themes as well as other circumstances identified from qualitative studies are detailed further in Table 4A.
Among the 15 studies that reported quantitative socio-demographic data or information on circumstances associated with abortion later in pregnancy, the most commonly reported characteristics and circumstances include low economic status or unemployment (10 studies); adolescence or young age (9 studies); health system challenges (8 studies); and late pregnancy recognition (7 studies). A full list of sociodemographic or other characteristics associated with seeking an abortion later in pregnancy, from quantitative data are shown in Table 4B.
Navigating health system obstacles was reported in all 12 of the analyses of qualitative data and eight of the studies with quantitative data (two studies contained both) [2, 5–7, 18, 19, 21, 22, 47–49, 53, 58, 63, 67, 79, 89]. These health system challenges included several issues including lack of information on where and how to access care and limited provider availability (see Table 4 for full list). Late pregnancy recognition also emerged as a common theme related to seeking an abortion later in pregnancy, identified in ten qualitative and seven quantitative studies (one study contained both) [2, 5–7, 18, 19, 21, 22, 42, 47–49, 53, 58, 63, 67, 79]. Further explanation for late pregnancy recognition included irregular menses; current contraceptive use; lack of pregnancy symptoms; unawareness of pregnancy symptoms; misinformation given by or misunderstandings with health professionals about contraception (Table 4). These circumstances led women to wait until the second or third month of a missed period before seeking pregnancy confirmation which contributed to delays in seeking care [19]. Similarly, participants of a different study reported monthly bleeding that they attributed to menses, leading them to believe they were not pregnant [47].
Participants in eight qualitative studies reported financial challenges that contributed to delays in their ability to access abortion care until later in pregnancy [5–7, 18, 48, 53, 58, 63]. Similarly, low economic status or unemployment was associated with seeking abortion care later in 10 studies with quantitative data [22, 25, 30, 42, 48, 49, 63, 67, 76, 78]. These challenges included needing time to raise money for the procedure and for travel in some cases.
Decision delays were part of the circumstances for needing an abortion later in pregnancy in seven studies with qualitative data and four with quantitative data [7, 18, 19, 21, 22, 42, 47, 53, 58, 79, 89]. These decision-making delays were described as ambivalence; uncertainty; needing time to decide; and weighing many competing and intersecting factors when making their decisions such as concerns for the health and well-being of existing children, financial constraints, expectations from family members, their current gestational age, and the desire to carry a pregnancy to term. Decision-making delays intersected with health system barriers and stigma to compound and extend service delays [5, 6, 18, 19, 48, 63, 89] (Table 4).
Reports of population and facility-based proportion of abortions later in pregnancy
Seventeen studies contained reports of population-based proportion of abortion later in pregnancy (≥12 weeks of gestation or labeled as second trimester) from national, subnational, and community-based data sources. These studies included data from eight countries and reported proportions of abortions later in pregnancy that ranged from 2–33% of all abortions [4, 80]. There was a lack of standardized categorization when reporting duration of gestation and known methodological limitations to direct reporting of abortion in surveys [91, 92], which partially explains this wide range.
Forty-five studies contained facility-based reports of proportion of abortions later in pregnancy. These studies reported varying populations, varying number of facilities, different denominators, and non-standardized categories for abortion occurring later in pregnancy. Studies with a reported proportion of abortion later in pregnancy are listed with any additional context explaining the reported proportion in Table 5. These descriptions include information on the settings, populations, care facility, or other factors.
Discussion
We provide a comprehensive scoping review of existing literature that reports circumstances of abortion later in pregnancy, associated sociodemographic or other characteristics, and/or reports of population and facility-based proportion of induced abortion occurring later in pregnancy. Overall, we show a dearth of studies in this area; with only 30 countries represented and some countries over-represented. Our findings revealed themes across settings such as health system challenges, delayed pregnancy recognition, financial challenges, and delayed decision-making that contributed to the circumstances of abortion later in pregnancy. Reports of proportion of abortions occurring later in pregnancy lack standard definitions, terminology, and measures for abortion later in pregnancy.
These findings elucidate the contexts and circumstances in which individuals need later abortions and provide insight into policy and health system solutions. Further, young people and those with lower levels of income were over-represented among those who need abortion later in pregnancy. Universal access to sexual and reproductive health information and services is a key strategy towards improving sexual and reproductive outcomes and ensuring individual and population health and respect for human rights [3] and will contribute to progress towards Sustainable Development Goals [94]. People have and will continue to need abortion later in pregnancy, so it is important to understand patterns in circumstances surrounding seeking care.
Studies that report the circumstances surrounding seeking an abortion later in pregnancy illustrate that people are seeking and accessing abortion care later for overlapping and intersecting reasons that compound and extend delays. Late pregnancy recognition puts people at a disadvantage for accessing care early, and financial and health system challenges accessing care extend those delays further. Reproductive awareness such as knowledge of menstrual cycle, knowing how one gets pregnant, what to expect with using contraceptive methods, and when/how to test is critical to pregnancy detection [95]. Adolescents and young people are less likely to recognize or experience early symptoms of pregnancy [96], resulting in delays in care seeking. Delays in care can also lead to denial of services due to legal restrictions on gestational limits. These restrictions can compound and extend delays further when people need to travel to access care [2, 48, 70, 76, 80]. Previous work has shown that denial of abortion can have negative consequences on health, social, and economic outcomes [97–99].
Our findings of a wide range of estimates of the proportion of abortions that are later in pregnancy highlight a key gap: we lack standard terminology, definitions, and measures for abortion later in pregnancy both in population- and facility-based analyses. In addition, population-based data are sparse; abortion incidence data are challenging to collect, especially in legally restricted settings and for abortion later in pregnancy [100]. Caution must be used in interpreting and comparing results from different studies. Quantitative reports of abortion later in pregnancy do not share common definitions or standardized categories when reporting duration of gestation, and some studies use trimesters or months gestation as opposed to weeks. Trimester language is not preferred because it lacks specificity and is clinically not useful [101]. Differential definitions, terminology, and measures make it impossible to directly compare studies and difficult to interpret findings across studies and settings.
Facility-based studies of the proportion of abortions later in pregnancy present distinct limitations. The studies we included that presented facility-based proportions of abortions later in pregnancy were based on nonrepresentative samples of people who were admitted to facilities or who sought post-abortion care for a suspected complication. Facility-based samples were biased both towards higher proportions of abortion ≥12 weeks and higher incidence of complications, because, by definition, only abortions that resulted in facility-based care for complications or concerns were being counted. Abortions that occurred at later weeks of gestation that were uncomplicated were not recorded in these studies. Although the risk of complications increases with weeks of gestation [102], abortions later in pregnancy are safe [103], and abortion at any stage in pregnancy is safer than childbirth [104]. In addition, often a limited number of facilities have the capabilities to provide abortion care at later gestations, so facility data were often over representative of people who had traveled and those with more significant care needs. For example, a study we included from Ethiopia reported high proportions of abortions at 13–20 and >20 weeks of gestation (15.1% & 38.2% respectively), but also noted that the facility was a large tertiary hospital that received many referrals and complicated cases [79]. Therefore, caution must be taken when interpreting facility-based reports of proportions of abortion at later weeks of gestation; they are not the same as population-level estimates.
Legal restrictions on abortion significantly impede the collection of comprehensive high-quality data at the facility and population levels [100]. Individuals are unlikely to disclose their experiences due to stigma and fear of legal repercussions and indirect methods used to measure abortion incidence do not account for pregnancy duration [105]. These barriers contribute to the scarcity of population-based data and standardized measures for abortion later in pregnancy, as highlighted by the variability and lack of consistency in existing studies in this review. Addressing these data challenges and advocating for universal access to sexual and reproductive health services is important for understanding evidence gaps, enhancing the quality of care, and ensuring informed policy making that supports reproductive health and rights globally.
This scoping review must be interpreted with some limitations in mind. This review relied on published reports of proportions of abortions later in pregnancy; we did not access large scale population-based surveys or official data sources of ministries of health, therefore no conclusions can be drawn about the prevalence of abortion ≥12 weeks and we do not calculate incidence of abortions. However, we do highlight gaps in data variability and availability in the literature and suggest the need for a unified approach for categorizing abortion later in pregnancy in future research. Data extraction was conducted by one author (LJ), although the team met regularly and discussed the inclusion/exclusion of papers when there was uncertainty. We excluded studies that were solely focused on spontaneous abortion, those that did not distinguish between induced and spontaneous abortion, and studies that focused only on abortion for non-viable pregnancies or congenital anomalies; however, this may result in under reporting because some people who present for induced abortion care may not report it as such due to stigma and fear of legal repercussions. This scoping review also has strengths: a standardized, transparent, and comprehensive multi-database search, and the inclusion of quantitative and qualitative studies published in English, Spanish, French, or Portuguese.
Conclusion
The majority of abortions occur early in pregnancy. Circumstances surrounding abortions occurring later in pregnancy include health system challenges, late pregnancy recognition, financial issues, and delayed decision-making which are often intersecting and compounded, resulting in extended delays as weeks of gestation increase. Young people and those with lower levels of income were over-represented among those who need abortion later in pregnancy. Policies should facilitate access to safe abortion care with minimal delays. More research guided by clear methods and standard definitions when reporting on population and facility-based proportions of abortions later in pregnancy is needed to better inform policies and programs.
Supporting information
S1 Table. Bibliographic database search strategy for OVID/PubMed.
https://doi.org/10.1371/journal.pgph.0003965.s001
(XLSX)
Acknowledgments
The authors wish to acknowledge Oregon Health & Science University librarian Laura Zeigen for assistance conducting the literature searches.
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