SUMMARY POINTS

Delays underpinned by economic, geographic, and legislative factors can impact abortion care-seeking, affect the type of care sought, and delay when care is sought. (Coast 2021)
People delayed in recognizing their pregnancies are more likely to lack pregnancy symptoms, to be using hormonal contraception, to have never previously had a birth, and to have health conditions with symptoms similar to pregnancy. (Foster 2021) Interventions to improve early identification of pregnancy should be encouraged, including efforts to educate patients about the signs and symptoms of pregnancy. (ACOG 2017)
Poverty and poor health increase likelihood of delays in abortion, worse health and economic outcomes, or being denied abortion. (Foster 2022, Jones 2012)
Dilation and evacuation (D&E) compared to medications for labor induction for abortion beyond the first trimester offers more predictable timing and advantages in safety, cost, and patient preference. (Paul et al (eds) 2009, ACOG 2017)
Medication induction may be done in settings where few providers are trained in D&E, where sterility is limited, or where restrictions limit its use. (Guttmacher, 2023)

Pregnant people presenting for delayed care may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate increased risk with preprocedural planning, intraoperative preparedness, and referral as needed to a higher level of care. (Henkel 2022)
Adequate cervical preparation significantly reduces the risk of complications for abortions beyond ≥ 14 weeks EGA (Peterson 1983, Shultz 1983). Routine ultrasound guidance reduces the risk of uterine perforation in training settings. (Darney 1989)
Prior cesarean section(s) are the most significant risk factor associated with abortion complications > 14 weeks EGA due to increased bleeding risk, with or without placenta accreta spectrum, and perforation in the setting of distorted anatomy. (Henkel 2022)

Depending on legal constraints in your state, providers may use formal or informal referral networks, with warm lines for second opinions or hand-off using pager or cell phone.
As a provider, you play an important role in setting tone, helping with later abortion values exploration, and normalizing the likelihood of seeing more complex patients arriving without work-up post-Dobbs.

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