Second-trimester abortion: women often lack the choice they should be offered.

In this issue, Koh et al. 1 from Singapore report on their randomised study of three vaginal prostaglandin regimens for mid-trimester termination of pregnancy.2 This article addresses gaps in knowledge both of the optimum dose of the most commonly used agent, misoprostol, and of the relative efficacy of the product licensed for this indication, gemeprost. But the question of whether medical termination is, in fact, the most suitable approach for termination after the first trimester remains open to debate. Over the past 20 years, the overall abortion rate in England and Wales, where figures are believed to be compiled with a high degree of accuracy, has plateaued at around 16/1000 women aged 15–44 years. In 2016, over 80% of procedures were undertaken at under 10 weeks’ gestation, with a continuing rise in the proportion utilising early medical abortion.3 However, the proportion of abortions carried out at 13 weeks’ gestation or above has remained static at around 8% and is unlikely to change in the foreseeable future. Mid-trimester abortion will continue to be necessary for a range of reasons including some women’s ambivalence about their decision, women not recognising their pregnancy due to contraceptive use or because they believe that they are infertile due to their age or medical factors, concealed pregnancies (particularly in teenagers), difficulty in engaging services due to mental health problems or learning difficulties, pregnancies that were initially wanted but where the woman’s circumstances have changed, and where serious fetal abnormality has been diagnosed.4 The introduction of more …