WOMEN’S HEALTH
Determinants of Late Presentation for
Induced Abortion Care
Ashley Waddington, MD, MPA, FRCSC, Philip M. Hahn, MSc, Robert Reid, MD, FRCSC
Department of Obstetrics and Gynaecology, Queen’s University, Kingston ON
Abstract
Objective: To determine whether demographic or patient factors
contribute to later presentation (10 to 12 weeks’ gestational age)
for induced abortion in a Canadian abortion clinic.
Methods: Women attending a hospital-based abortion clinic between
April and September 2012 were asked to complete a survey. The
characteristics of women who presented early (EPs; gestational
age < 10 weeks) were compared with those of late presenters
(LPs; gestational age ≥ 10 weeks) using t tests for means and
Fisher exact tests for rates.
Results: Among women referred to the clinic by a primary care
provider, LPs were more likely than EPs to report “a delay in
obtaining a referral” (20.8% vs. 6.1%; P = 0.007). While there
was no significant difference between the groups in reporting that
“someone tried to discourage [them] from having an abortion”
(26.45% for EPs, 32.4% for LPs; P = 0.421), LPs were more
likely to report that discouragement “caused a delay in making
arrangements” (45.5% vs. 16.7%; P = 0.019). Of women who had
access to a primary care provider, it was more common for the
primary care provider to be aware of the pregnancy among LPs
than among EPs (80.6% vs. 63.1%; P = 0.015).
Conclusion: Some women delay presenting for abortion because
of discouragement from friends and family. It is unclear whether
there are educational or policy interventions that can have an
impact on this delay, and this warrants further study. There may be
ways of addressing the delay in referral by primary care providers.
Further study into the causes for delay in referral for abortion is
warranted.
Key Words: Abortion, delayed presentation, gestational age
Competing Interests: None declared.
Received on June 30, 2014
Accepted on September 10, 2014
40 l JANUARY JOGC JANVIER 2015
Résumé
Objectif : Déterminer si des facteurs démographiques ou liés à la
patiente contribuent au fait de se présenter tardivement (âge
gestationnel : 10-12 semaines) dans une clinique d’avortement
canadienne pour l’obtention d’un avortement provoqué.
Méthodes : Nous avons demandé aux femmes ayant fréquenté une
clinique d’avortement en milieu hospitalier entre avril et septembre
2012 de remplir un questionnaire. Les caractéristiques des
femmes s’étant présentées tôt (âge gestationnel < 10 semaines)
ont été comparées aux caractéristiques des femmes s’étant
présentées tard (âge gestationnel ≥ 10 semaines) au moyen de
tests t (pour les moyennes) et de tests exacts de Fisher (pour les
taux).
Résultats : Chez les femmes orientées vers la clinique par un
fournisseur de soins primaires, les femmes s’étant présentées tard
étaient plus susceptibles que les femmes s’étant présentées tôt de
signaler « un délai quant à l’obtention d’une orientation » (20,8 %
vs 6,1 %; P = 0,007). Bien qu’aucune différence significative n’ait
été constatée entre les groupes pour ce qui est du fait de signaler
que « quelqu’un avait tenté de les convaincre de ne pas subir un
avortement » (26,45 % des femmes s’étant présentées tôt, 32,4 %
des femmes s’étant présentées tard; P = 0,421), les femmes
s’étant présentées tard étaient plus susceptibles de signaler
qu’une telle intervention « avait causé un délai pour ce qui est
de la prise des mesures nécessaires » (45,5 % vs 16,7 %;
P = 0,019). Chez les femmes qui avaient accès à un fournisseur
de soins primaires, il était plus fréquent que ce dernier soit
au courant de la grossesse dans le cas des femmes s’étant
présentées tard que dans celui des femmes s’étant présentées tôt
(80,6 % vs 63,1 %; P = 0,015).
Conclusion : Certaines femmes tardent à chercher à obtenir un
avortement en raison des efforts qui sont déployés par des amis
et des membres de la famille pour chercher à les en dissuader. La
question de savoir s’il existe des interventions pédagogiques ou
de politique pouvant exercer un effet sur ce délai demeure sans
réponse, ce qui justifie la tenue d’autres études. Il pourrait y avoir
des façons d’aborder ce délai en matière d’orientation lorsqu’il est
lié aux fournisseurs de soins primaires. La tenue d’autres études
quant aux causes de délai pour ce qui est de l’orientation vers des
services d’avortement s’avère justifiée.
J Obstet Gynaecol Can 2015;37(1):40–45

INTRODUCTION
T he morbidity and mortality associated with elective
pregnancy termination increases with gestational age.
The risks of immediate complications such as uterine
perforation or hemorrhage, as well as later complications
such as infection, increase in a linear fashion in the first
trimester, and then increase exponentially in the second
trimester.1–5
Challenges to finding or accessing abortion services,
particularly those due to clinic location, restrictive legal
environments, and financial barriers, may account for
delayed presentation for some women. Multiple studies have
examined the demographic variables and patient factors
that may contribute to later (rather than early) presentation
for abortion care.6–18 To our knowledge, only one study
(unpublished) has taken place in a Canadian context.9
The results of studies of demographic variables that
contribute to late presentation for abortion have been
conflicting. A study in Singapore8,16 determined that
adolescents were more likely to present late for abortion
care, while a retrospective Canadian study (unpublished)9
found that older age was associated with later presentation.
A study in the United States7 suggested that adolescents
and economically disadvantaged women were more likely
to present later for abortion, but that the reasons for
doing so were different. Adolescents were more likely to
have a delay in recognizing that they were pregnant, while
economically disadvantaged women did not appear to have
a delay in recognizing their pregnancies but were more likely
to have a delay between deciding to obtain an abortion
and being able to make the arrangements to have one.
Studies performed in the United States7,10 demonstrate that
issues related to obtaining funding for abortion care are
associated with delayed presentation. In a publicly funded
system, such as in Canada, concerns regarding financial
barriers to abortion care should be less prominent. We
are not aware of any studies examining whether or not
challenges of reciprocal billing between provinces have
impeded Canadian women’s ability to access abortion care
in a timely fashion. Studies in the United States also suggest
that restrictive legal environments surrounding access to
abortion care can cause delays in presentation.12 In Ontario,
where our study took place, there are few legal restrictions
that would prevent or delay women who attempt to access
abortion care. In some provinces in Canada, particularly
New Brunswick, restrictive policies regarding funding for
abortion may play a role in delaying access to care.9,19
By determining whether there are demographic or patient
factors in Canadian women that are associated with
Determinants of Late Presentation for Induced Abortion Care
late presentation for abortion, interventions could be
developed to target those at risk of late presentation to
facilitate access to abortion care earlier in gestation.
METHODS
We designed a survey-based study to assess factors
associated with later presentation (defined as ≥ 10 weeks’
gestational age) for induced abortion. Women attending
the only abortion clinic located in a medium-sized city
in Ontario (with a referral population of approximately
1 million) between April 2012 and September 2012
were asked to complete a survey that included questions
designed to assess several factors previously identified
as being associated with late presentation for abortion
care. These factors included patient characteristics such
as age, occupation, parity, previous obstetric history,
contraception use, rural versus urban place of residence,
access to primary care physician, distance travelled to the
clinic and associated travel costs, relationship to the father
of the pregnancy, and social supports.
The clinic offers medical abortion to women presenting up
to seven weeks’ gestational age, and surgical abortion services
up until 12 weeks’ gestational age. Women may self-refer
to the clinic or be referred by a health care provider. Once
the woman or her health care provider has contacted the
clinic, appointments are arranged within seven to 10 days in
almost all cases. When women are already beyond 10 weeks’
gestational age at the time they contact the clinic, an effort
is made to expedite their appointment so that they can have
their procedure performed in the clinic; if not, they would
need to be referred to another facility for the procedure to
be performed after 12 weeks. The two facilities to which
women over 12 weeks’ gestational age are referred are 200 km
and 260 km away, respectively. As the wait time is equal for
all women, with the exception of those who make initial
contact with the clinic after 9+6 weeks’ gestation (who
would already be considered “late presenters” in this study),
a delay in obtaining an appointment in the clinic once initial
contact has been made would be unlikely to have changed
the distribution of early and late presenters in the study or
impacted the study results.
All women attending the clinic had had at least one
ultrasound examination to confirm an intrauterine
pregnancy and to accurately assess gestational age. In
this study all gestational ages were based on ultrasound.
Gestational age on the day of the patient’s procedure was
correlated with the surveys by having a clinic nurse write
the gestational age on the outside of each survey envelope
as the surveys were handed in.
JANUARY JOGC JANVIER 2015 l 41
Women’s Health
Data were collected and descriptive statistical analysis was
performed using SPSS v. 21 (IBM Corp., Armonk NY).
Determinants for early presenters (EPs, ≤ 9+6 weeks) and
late presenters (LPs, ≥ 10 weeks) were compared using
GraphPad InStat v 3.06 (GraphPad Software Inc., La Jolla,
CA) with the t test used for comparing means, and the
Fisher exact test for comparing rates.
Research ethics approval was obtained from the Queen’s
University Human Research Ethics Board before initiation
of the study.
RESULTS
Of 255 surveys distributed, 227 were included in the
analysis, giving a response rate of 89.0%. Comparing
gestational ages between the non-responders (n = 28)
and responders (n = 227) did not show a significant
difference (0.2 weeks; P = 0.347). Therefore, the findings
in this survey did not appear to suffer from non-response
bias.
In the surveys analyzed, 70% of respondents were EPs
(159/227), while 30% were LPs (68/227). EPs and LPs
did not differ significantly in demographic characteristics
(Table). The average age of respondents was 25.5 years
(range 14 to 46). The majority of respondents lived in
an urban setting, with 94.3% of respondents (214/227)
indicating that they live in or near a city. Travel to the clinic
was by personal car for 84.1% of respondents (190/226),
by taxi for 5.3% (12/226), and 7.5% (17/226) walked to the
clinic. Approximately one quarter of respondents (26.3%,
59/224) stated that they had to pay to travel to the clinic,
with a range of cost between $2 and $400 and an average
cost of $40.95. Despite these women having to pay for
transportation to attend the clinic, only 8.0% (18/225)
agreed that “transportation was a challenge.” None of the
preceding values were significantly different between EPs
and LPs.
Overall, the survey respondents reported a high rate of
smoking: 54.6% of respondents (124/227) stated that they
had smoked cigarettes in the past three months. There was
no significant difference in the rate of smoking between
EPs and LPs. EPs and LPs were equally likely to have
access to a primary care provider, and 93.8% of the whole
cohort (213/227) had such access. In the majority of
cases (68.2%, 144/213) the primary health care provider
was aware of the current pregnancy. LPs were more likely
than EPs to report that their primary care provider was
aware of the current pregnancy (80.6%, 50/62, vs. 63.1%,
94/149; P = 0.015).
42 l JANUARY JOGC JANVIER 2015
The father of the pregnancy was involved in the decision
process that led to abortion in 86.7% of cases (195/225),
but was only described as being supportive of the decision
in 67.4% of cases (116/172). There were no significant
differences between EPs and LPs in either of these factors.
The survey included several questions about previous
reproductive history. More than one half of the
respondents (62.25%, 140/225) had had at least one
pregnancy before the current presentation, 79.3% of those
who had previously been pregnant (111/140) had had at
least one previous live birth, and 43.9% of respondents
(61/139) had had at least one induced abortion before their
current presentation. There were no significant differences
between EPs and LPs in these characteristics.
When asked how likely they thought they were to become
pregnant at the time they conceived the current pregnancy,
42.7% of respondents (97/227) had thought it was “unlikely,”
while 15.9% (36/227) had thought it was “impossible” for
them to become pregnant. Fifteen percent of respondents
(34/227) had thought their risk of pregnancy was “around
50%,” while 18.5% (42/227) were “not sure.” Only 7.9%
(18/227) of respondents had thought they were “likely”
to conceive. Of all respondents, 14.1% (32/227) reported
that they “considered using emergency contraception” at
the time they conceived their pregnancy, but only 46.8% of
those women (15/32) actually used it, representing 6.6% of
all study participants. There were no differences between
EPs and LPs in these characteristics.
Survey respondents reported high rates of contraception
use at the time they conceived. More than one half
(64.2%,145/226) reported using some form of
contraception, with condoms being the most popular
method (48.3%, 70/145) and oral contraceptives being
the next most common method (35.2%, 51/145). Of the
respondents using contraception, 11.7% (17/145) were
using “natural family planning” methods, and 15.9%
(23/145) were using withdrawal (coitus interruptus).
Respondents were allowed to enter more than one choice
of contraceptive method, as some were using more than
one method concurrently. There were no significant
differences between EPs and LPs in either their likelihood
of using contraception, or the methods used.
Responses to five questions on the survey were significantly
different between EPs and LPs (Table). Of women who
had access to a primary care provider, LPs were more likely
than EPs to report that their primary care provider was
aware of the current pregnancy (80.6 vs. 63.1%; P = 0.015).
In women who were referred to the abortion clinic by
their primary care providers, LPs were more likely than
 Determinants of Late Presentation for Induced Abortion Care

Characteristics of early and late presenters for abortion care

Early presenters Late presenters
gestational age gestational age
< 10 weeks ≥ 10 weeks
Characteristic (n = 159) (n = 68) P
Mean age of subjects in years ± SD (range) 25.8 ± 6.6 (15 to 46) 24.8 ± 5.9 (14 to 40) 0.303*
n = 158 n = 65
Living in or near a city 94.3% (150/159) 94.1% (64/68) > 0.99†
Living within the clinic city or within a half an hour drive 67.5% (106/157) 61.8% (42/68) 0.445†
Smoking in past 3 months 52.2% (83/59) 60.3% (41/68) 0.309†
Alcohol intake in past 3 months 76.1% (121/159) 48.5% (33/68) < 0.001†
Illicit drug use in past 3 months 22.9% (36/157) 41.8% (28/67) 0.006†
Having access to regular health care provider such as a 93.7% (149/159) 94.1% (64/68) 1.000†
family doctor
In those with access to regular health care provider, the 63.1% (94/149) 80.6% (50/62) 0.015†
primary care provider was aware of pregnancy
Delay in obtaining referral by primary care provider 6.1% (7/115) 20.8% (11/53) 0.007†
Using any form of contraception 65.2% (103/158) 61.8% (42/68) 0.652†
Was discouraged by someone from having an abortion 26.4% (42/159) 32.4% (22/68) 0.421†
If someone discouraged patient, this led to delay in obtaining 16.7% (7/42) 45.5% (10/22) 0.019†
abortion
Mean number of pregnancies ± SD (range) 2.5 ± 2.0 (1 to 17‡) 2.6, 1.7 (1 to 7) 0.777*
n = 158 n = 67
*t test
†Fisher exact test
‡One subject reported 17 pregnancies

EPs to report that they encountered “a delay in obtaining
a referral” (20.8% vs. 6.1%; P = 0.007). While there was
no statistically significant difference between the groups in
the number of women who reported that “someone tried
to discourage [them] from having an abortion” (26.45%
for EPs vs. 32.4% for LPs, P = 0.421), LPs were more
likely to report that the discouragement “caused a delay in
making arrangements for the abortion” (45.5% vs. 16.7%;
P = 0.019). EPs were more likely to report that they had
“alcohol intake within the last 3 months” compared with
LPs (76.1% vs. 48.5%; P = 0.001). LPs were more likely to
report “drug use in the last three months” compared with
EPs (41.8% vs. 22.9%; P = 0.006) (Table).
DISCUSSION
Almost 60% of respondents in this survey had felt that
pregnancy was unlikely or impossible in their particular
circumstances. This could have contributed to delay in
diagnosis of their pregnancy and subsequent delay in
obtaining abortion care, as has been reported in some prior
studies.7 However, we found no difference between EPs
and LPs in this characteristic. Respondents were not asked
why they had thought they were unlikely to get pregnant,
but this interesting finding warrants further research into
women’s knowledge about their fecundity as well as their
knowledge of contraceptive effectiveness. In particular,
the low rates of emergency contraception use suggest
that increased knowledge and awareness of contraception
that can be used post-coitally could reduce the unintended
pregnancy rates in the population studied.
Both EPs and LPs were equally likely to have been
discouraged from having an abortion, but LPs were more
likely to report that this influenced the time it took for
them to arrange their abortion. There could be several
reasons for this. It may be that the woman herself was
ambivalent about the decision and therefore more
susceptible to discouragement; it may be that the severity
of the discouragement was different between the groups,
or that it came from a different source, which may have
had a different impact on the woman. Deciding to undergo
induced abortion will always be difficult, and women will
likely continue to seek advice from friends and family
regarding their decision. Health care providers must strive
to ensure that they are non-judgemental in their discussions
with patients, and give objective and evidence-based advice
regarding abortion care. Policy-makers can work to ensure

JANUARY JOGC JANVIER 2015 l 43

Women’s Health
that men and women have access to unbiased advice
and counselling, as well as to rigorous school-based sex
education programs. This will help to ensure that women
who are struggling with their decision will not be influenced
by rumours or myths about the procedure, but rather will
be guided by their own priorities and values.
Compared with EPs, LPs were more likely to report that
their primary care provider was aware of their pregnancy
and that there was a “delay in obtaining a referral” for
abortion care from their primary health care providers. The
survey was not designed to determine what the delay may
have been, but, based on unsolicited write-in responses, in
at least a few cases the delay may have been deliberately
caused by a family physician who was trying to prevent
a patient from obtaining an abortion. Most delays were
probably not intentionally caused, but may have been due
to logistic challenges in booking timely appointments to be
assessed by the primary health care provider, or to delays in
the administrative process of filling out a referral form and
getting it to the abortion clinic in a timely fashion. In our
clinic, faxed referrals receive a response within two business
days. Patients are required to have undergone an ultrasound
examination to confirm that the pregnancy is intrauterine
and to determine gestational age before their procedure
at the abortion clinic, although the clinic will assist in
arranging for the ultrasound examination if the patient’s
family doctor is unable or unwilling to arrange it. We have
not observed a substantial delay in accessing ultrasound
services; at our centre, women report an average wait of
4.75 days to undergo ultrasound examination after either
contacting the abortion clinic or contacting their health
care provider (range 0 to 30 days, median 7 days). There
could, however, be a delay between the ultrasound being
performed and the report being seen by the primary care
provider and incorporated into a referral to the abortion
clinic. Additional research is needed to fully understand
the causes of delay in obtaining referrals for abortion
from primary care providers. In addition, the correlation
between later presentation and higher rates of primary
care providers being aware of the pregnancy warrants
further investigation, because this correlation is difficult to
explain. This may be an area in which health care providers
and policy makers could help decrease the likelihood of
late presentation. One step that should be taken in our
community is to ensure that women are aware that they can
self-refer to the abortion clinic and that the abortion clinic
will arrange for them to have their ultrasound assessment
before their appointment. This would make it easier for
women who do not have a primary care provider, or who
are encountering a delay in referral by their primary care
provider, to access abortion care more quickly.
44 l JANUARY JOGC JANVIER 2015
High rates of alcohol and drug use in respondents were
an interesting finding, but we cannot explain why there
was a difference in these between the EPs and LPs. The
difference is likely spurious.
CONCLUSION
In this Canadian study of patient and demographic
variables contributing to later presentation for abortion
care, none of the factors that have been described in
previous studies were found to differ between EPs and
LPs. Factors such as distance travelled to the clinic or
the cost of arranging transportation were not different
between EPs and LPs. Factors with differences between
EPs and LPs in this study included alcohol consumption
(more common in EPs), drug use (more common in LPs),
being discouraged from having an abortion, primary
care providers’ awareness of the pregnancy, and delays
in obtaining a referral from a primary care provider.
Educational or policy interventions might reduce delays in
presentation caused by discouragement from friends and
family. There may be ways of addressing the reported delay
in referral by primary care providers, including education
about the opportunity for self-referral. Further study into
the causes for delay in referral is warranted, in order to
ensure that women have timely access to abortion care.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Ms Sarah Edgerley
who assisted with data entry, and the staff at the Kingston
General Hospital Women’s Clinic.
REFERENCES
1. Ferris LE, McMain-Klein M, Colodny N, Fellows GF, Lamont J.
Factors associated with immediate abortion complications. CMAJ
1996;154(11):1677–85.
2. Bartlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S,
Atrash HK. Risk factors for legal induced abortion-related mortality in the
United States. Obstet Gynecol 2004;103(4):729–37.
3. Cates JW, Schulz KF, Grimes DA, Tyler JCW. The effect of delay and
method choice on the risk of abortion morbidity. Fam Plann Perspect
1977;9(6):266–73.
4. Heisterberg L, Kringelbach M. Early complications after induced first-
trimester abortion. Acta Obstet Gynecol Scand 1987;66(3):201–4.
5. Heisterberg L, Sonne-Holm S, Andersen JT, Hebjørn S,
Dyring-Andersen K, Hejl BL. Risk factors in first-trimester abortion.
Acta Obstet Gynecol Scand 1982;61(4):357–60.
6. Buehler JW, Schulz KF, Grimes DA, Hogue CJ. The risk of serious
complications from induced abortion: do personal characteristics make
a difference? Am J Obstet Gynecol 1985;153(1):14–20.
7. Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing of
steps and reasons for delays in obtaining abortions in the United States.
Contraception 2006;74(4):334–44.

8. Lim L, Wong H, Yong E, Singh K. Profiles of women presenting for
abortions in Singapore: focus on teenage abortions and late abortions.
Eur J Obstet Gynecol Reprod Biol 2012;160(2):219–22.
9. Brooks M, Roberts S, Waddington A. The effect of travel distance on the
gestational age at which women present for abortions in New Brunswick
Oral presentation, Society of Obstetricians and Gynaecologists of Canada
Annual Clinical Meeting 2012; Ottawa, ON.
10. Drey EA, Foster DG, Jackson RA, Lee SJ, Cardenas LH, Darney PD.
Risk factors associated with presenting for abortion in the second
trimester. Obstet Gynecol 2006;107(1):128–35.
11. Kumar U, Baraitser P, Morton S, Massil H. Decision making and referral
prior to abortion: a qualitative study of women’s experiences. J Fam Plann
Reprod Health Care 2004;30(1):51–4.
12. Bitler M, Zavodny M. The effect of abortion restrictions on the timing of
abortions. J Health Econ 2001;20(6):1011–32.
13. Foster DG, Jackson RA, Cosby K, Weitz TA, Darney PD, Drey EA.
Predictors of delay in each step leading to an abortion. Contraception
2008;77(4):289–93.
Determinants of Late Presentation for Induced Abortion Care
14. Kiley JW, Yee LM, Niemi CM, Feinglass JM, Simon MA. Delays in request
for pregnancy termination: Comparison of patients in the first and second
trimesters. Contraception 2010;81(5):446–51.
15. Gallo MF, Nghia NC. Real life is different: a qualitative study of why
women delay abortion until the second trimester in Vietnam. Soc Sci Med
2007;64(9):1812–22.
16. Singh K, Fong YF, Loh SY. Profile of women presenting for abortions
in Singapore at the National University Hospital. Contraception
2002;66(1):41–6.
17. Loeber O, Wijsen C. Factors influencing the percentage of second
trimester abortions in the Netherlands. Reprod Health Matters
2008;16(31 Suppl):30–6.
18. Lee E, Ingham R. Why do women present late for induced abortion?
Best Pract Res Clin Obstet Gynaecol 2010;24(4):479–89.
19. Shaw J. Reality check: a close look at accessing abortion services in
Canadian hospitals. Ottawa: Canadians for Choice; 2006.
JANUARY JOGC JANVIER 2015 l 45