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Abortion After the First Trimester in the United States

Since the legalization of abortion throughout the United States in 1973, abortion services have become more widely accessible, and knowledge about them has grown.  As a result, the overwhelming majority of abortions are performed in the first trimester of pregnancy.  For a number of reasons, however, abortion after the first trimester remains a necessary option for some women.

Unfortunately, anti-choice zealots seek to limit access to abortion through, among other means, laws imposing a fixed date for fetal viability and bans that would outlaw safe, medically appropriate abortions in the second trimester.  The hidden agenda of these zealots is to make all abortions illegal.

In fact, the same anti-choice activists who would limit access to abortions after the first trimester also oppose access to abortion in the first trimester by advancing numerous restrictions, including parental involvement laws and mandatory delay laws.  Also, by asserting their bias at a local level through picketing doctors’ homes and offices, clinic blockades, threats of violence against doctors, and the misapplication of zoning laws, etc., anti-choice activists create such a threatening climate that the number of qualified providers is diminished.  These actions endanger the health of women and the right of physicians to determine the most appropriate treatment for their clients.

The Number of Abortions After the First Trimester Is Relatively Small

  • Between 1996 and 2002, the number of abortions in the U.S. fell from 1.36 million to 1.29 million (Finer & Henshaw, 2003; Guttmacher Institute, 2006).  The U.S. Centers for Disease Control and Prevention (CDC) estimates that 60.5 percent of legal abortions occur within the first eight weeks of gestation, and 88.2 percent are performed within the first 12 weeks. Only 1.4 percent occur after 20 weeks (CDC, 2006).
  • Since the nationwide legalization of abortion in 1973, the proportion of abortions performed after the first trimester has decreased because of increased access to and knowledge about safe, legal abortion services (Gold, 2003).

Various Factors Require Women to Have Abortions After the First Trimester

Barriers to Service

  • Geographic — A 2001 survey of U.S. abortion providers found that among women who have non-hospital abortions, approximately 16 percent travel 50 to 100 miles for services, and an additional eight percent travel more than 100 miles (Henshaw & Finer, 2003).  It follows that having to travel such distances can cause delays in obtaining abortions.
  • Provider shortage — As of 2000, 87 percent of U.S. counties have no known abortion provider; these counties are home to 34 percent of all women of reproductive age.  Furthermore, 97 percent of non-metropolitan counties have no abortion services, and 91 percent of non-metropolitan women live in these unserved counties (Finer & Henshaw, 2003).
  • Financial — In 1997, the average cost of a first-trimester, non-hospital abortion with local anesthesia was $319.  In 2000 this cost was $372.  For low-income and younger women, gathering the necessary funds for the procedure often causes delays.  Compounding the problem is the fact that the cost of abortion rises with gestational age: in 2001, non-hospital facilities charged $774 for abortion at 16 weeks gestation and $1,179 at 20 weeks.  Most women are forced to pay for abortions out-of-pocket. In 2000, only 13 percent of abortions were paid by Medicaid and another 13 percent were billed directly to private insurance (Henshaw & Finer, 2003).  For some women, the cost of abortion can pose significant barriers to access.
  • Legal restrictions — Causing additional delays are state laws that mandate parental consent, notification, or court-authorized bypass for minors, and laws that impose required waiting periods.  For example, after Mississippi passed a parental consent requirement, the ratio of minors to adults obtaining abortions after 12 weeks increased by 19 percent (Henshaw, 1995).

Medical indications affecting the fetus or the woman may also lead to abortion after 12 weeks.

  • In a recent survey of U.S. women choosing to terminate their pregnancies, significantly more women in their second trimester cited fetal health concerns than women in their first trimester.  The fetal health concerns they cited included the risk of fetal anomaly due to advanced maternal age, a history of miscarriage, a lack of prenatal care, and fetal exposure to prescription medications and non-prescription substances (Finer et al., 2005).

  • Conditions in which the woman’s health is threatened or aggravated by continuing her pregnancy include
      • certain types of infections
      • heart failure
      • malignant hypertension, including preeclampsia
      • out-of-control diabetes
      • serious renal disease
      • severe depression
      • suicidal tendencies

These symptoms may not occur until the second trimester, or they may become worse as the pregnancy progresses (Cherry & Merkatz, 1991; Paul et al., 1999).

Other Reasons for Having an Abortion Past 12 Weeks

  • absence of partner due to estrangement or death
  • lack of financial and/or emotional support from partner
  • lack of pregnancy symptoms, seeming continuation of "periods," irregular menses
  • psychological denial of pregnancy, as may occur in cases of rape or incest
    (Ingram et al., 2007; Paul et al., 1999)

Adolescents Often Delay Abortion Until After the First Trimester

  • Adolescents are more likely than older women to obtain abortions later in pregnancy.  Adolescents obtain approximately 25 percent of all abortions performed after the first trimester (CDC, 2006).

  • Among women under age 15, nearly one in four abortions are performed at 13 or more weeks' gestation (CDC, 2006).

  • The very youngest women  those under age 15  are more likely than others to obtain abortions at 21 or more week's gestation (CDC, 2006).

  • Common reasons why adolescents delay abortion until after the first trimester include fear of parents' reaction, denial of pregnancy, and prolonged fantasies that having a baby will result in a stable relationship with their partners (Paul et al., 1999).  In addition, adolescents may have irregular periods (Friedman et al., 1998), making it difficult for them to detect pregnancy.  Also, as previously noted, delays are often caused by state laws requiring parental consent or court-authorized bypass for minors.

Abortion After the First Trimester Is as Safe as / or Safer than Carrying a Pregnancy to Term

  • Overall, abortion has a low morbidity rate. Fewer than 0.3 percent of women undergoing legal abortion procedures sustain a serious complication (Boonstra et al., 2006; Henshaw, 1999).  The rate of complication increases by about 20 percent for each additional week of gestation beyond eight weeks (Paul et al., 1999).

  • The risk of death from medication abortion through 63 days' gestation is about one per 100,000 procedures (Grimes, 2005).  The risk of death with surgical abortion is about one per 1,000,000 through 63 days' gestation (Bartlett et al., 2004).  The risk of death from miscarriage is about one per 100,000 (Saraiya et al., 1999).  But the risk of death associated with childbirth is about 10 times as high as that associated with all abortion (Christiansen & Collins, 2006).

  • The risk of death associated with surgical abortion increases with the length of pregnancy, from one death for every one million abortions at eight or fewer weeks to 8.9 deaths for every one million abortions after 20 weeks’ gestation (Boonstra et al., 2006).  In comparison, the maternal mortality rate in the U.S., in 2003, was 12.1 deaths per 100,000 live births — a significant difference in maternal mortality rates between terminating a pregnancy by abortion after 20 weeks’ gestation and carrying it to term (Hoyert et al., 2006; Paul et al., 1999).

Current Law Guarantees Women the Right to Abortion After the First Trimester

Legality of Abortion

  • In Roe v. Wade (410 U.S. 113 (1973)), the U.S. Supreme Court held that the U.S. Constitution protects a woman's decision to terminate her pregnancy.  Only after the fetus is viable, capable of sustained survival outside the woman's body with or without artificial aid, may the states ban abortion altogether.  Abortions necessary to preserve the woman's life or health must still be allowed, however, even after fetal viability.

  • Prior to viability, states can regulate abortion, but only if the regulation does not impose a "substantial obstacle" in the path of a woman seeking an abortion (Harrison & Gilbert, 1993).

Determination of Viability

  • In Planned Parenthood® of Central Missouri v. Danforth (428 U.S. 52 (1976)), the U.S. Supreme Court recognized that judgments of viability are inexact and may vary with each pregnancy.  As a result, it granted the attending physician the right to ascertain viability on an individual basis.  In addition, the court rejected as unconstitutional fixed gestational limits for determining viability.  The court reaffirmed these rulings in the 1979 case Colautti v. Franklin (439 U.S. 379 (1979)).

State Laws and Abortion Facilities

  • In City of Akron v. Akron Center for Reproductive Health (462 U.S. 416 (1983)), the U.S. Supreme Court invalidated a costly requirement that all second-trimester abortions take place in a hospital.

Laws and Specific Abortion Techniques

  • In Thornburgh v. American College of Obstetricians and Gynecologists (479 U.S. 747 (1986)), the U.S. Supreme Court ruled that a woman may not be required to risk her health to save a fetus even after viability, and it granted the attending physician the right to determine when a pregnancy threatens a woman’s life or health.  The court also ruled that when performing a post-viability abortion, a physician must be permitted to use the method most likely to preserve the woman’s health, even if it might endanger fetal survival.

  • On April 18, 2007, in Gonzales v. Carhart (550 U.S. ___ (2007, April 18)) and Gonzales v. Planned Parenthood Federation of America, Inc. (550 U.S. ___ (2007, April 18)), the U.S. Supreme Court ignored 30 years of precedent that held women’s health must be the paramount concern in laws that restrict abortion access, and in a five-to-four decision, upheld the Partial-Birth Abortion Ban Act of 2003 (the “federal abortion ban”) — the first federal legislation to criminalize abortion.

  • The federal abortion ban, which does not contain an exception for the woman’s health, makes it a federal crime to take certain steps when performing an abortion after the first trimester.  Specifically, the ban prohibits “deliberately and intentionally vaginally deliver[ing] a living fetus” past certain anatomical landmarks “for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus (Partial-Birth Abortion Ban Act of 2003, 2003).”  The ruling allows Congress to ban certain second-trimester abortion procedures, despite the fact that doctors and major medical organizations, including the American College of Obstetricians and Gynecologists, believe the banned procedures are sometimes the safest and best to protect women’s health.

  • The recent Carhart and Planned Parenthood Federation of America, Inc. rulings may make it easier for states, as well as the federal government, to further limit a woman’s ability to choose abortion, especially after the first trimester.  This shift will likely spur state efforts to enact new abortion restrictions.

Protecting the Right to Choose Planned Parenthood Continues Its Fight

Despite the federal abortion ban taking effect, Planned Parenthood will continue to provide high-quality care, including second-trimester abortion services, to our clients.  Planned Parenthood will also continue to support vital efforts to protect access to abortion services at the state and federal levels.

Currently, seven states — California, Connecticut, Hawaii, Maine, Maryland, Nevada, and Washington — have passed Freedom of Choice Acts (FOCAs), and other states are seeking to pass similar legislation (Vestal, 2007).  Although state-level FOCAs have no impact on the federal abortion ban, such laws prohibit the state government from interfering with the right to choose to bear a child or end a pregnancy.

  • On April 19, 2007, Sen. Boxer (D–CA) and Rep. Nadler (D–NY), introduced the Freedom of Choice Act in both houses of Congress.  At the federal level, FOCA would prohibit state and federal government entities from denying or interfering with a woman’s right to choose to bear a child, to terminate a pregnancy before viability, or to terminate a pregnancy after viability when termination is necessary to protect the life or health of the woman (Freedom of Choice Act, 2007).

Cited References

Bartlett, Linda A., et al.  (2004).  “Risk Factors for Legal Induced Abortion-Related Mortality in the United States.”  Obstetrics & Gynecology, 103(4), 729–37.

Boonstra, Heather D., et al.  (2006).  Abortion In Women’s Lives.  New York:  Guttmacher Institute.

CDC — Centers for Disease Control and Prevention.  (2006, November 24).  “Abortion Surveillance — United States, 2003.”  Morbidity and Mortality Weekly Report, 55(SS-11).

Cherry, Sheldon & Irwin Merkatz, eds.  (1991).  Complications of Pregnancy:  Medical, Surgical, Gynecologic, Psychosocial, and Perinatal, 4th Edition.  Baltimore, MD:  Williams & Wilkins.

Christiansen, Lydia R. & Kim A. Collins.  (2006).  “Pregnancy-Associated Deaths:  A 15-Year Retrospective Study and Overall Review of Maternal Pathophysiology.”  American Journal of Forensic Medicine and Pathophysiology, 27(1), 11–9.

City of Akron v. Akron Center for Reproductive Health, 462 U.S. 416 (1983).

Colautti v. Franklin, 439 U.S. 379 (1979).

Finer, Lawrence B. & Stanley K. Henshaw.  (2003).  “Abortion Incidence and Services in the United States in 2000.”  Perspectives on Sexual and Reproductive Health, 35(1), 6–15.

Finer, Lawrence B., et al.  (2005).  “Reasons U.S. Women Have Abortions:  Quantitative and Qualitative Perspectives.”  Perspectives on Sexual and Reproductive Health, 37(3), 110–8.

Freedom of Choice Act, H.R.1964; S.1173, 110th Cong., 1st Sess.  (2007, April 19).

Friedman, Stanford B., et al.  (1998).  Comprehensive Adolescent Health Care, 2nd Edition.  St. Louis, MO:  Mosby.

Gold, Rachel Benson.  (2003).  “Lessons from Before Roe: Will Past be Prologue?”  The Guttmacher Report on Public Policy, 6(1), 8–11.

Gonzales v. Carhart, 550 U.S. ___ (2007, April 18).  [Online].

Gonzales v. Planned Parenthood Federation of America, Inc., 550 U.S. ___ (2007, April 18).  [Online].

Grimes, D.A.  (2005).  “Risks of Mifepristone Abortion in Context.”  Contraception, 71, 161.

Guttmacher Institute.  (2006, June, accessed 2007, April 24).  Facts on Induced Abortion in the United States.  [Online].

Harrison, Maureen & Steve Gilbert, eds.  (1993).  Abortion Decisions of the United States Supreme Court:  The 1990’s.  Beverly Hills, CA:  Excellent Books.

Henshaw, Stanley K.  (1995).  “The Impact of Requirements for Parental Consent On Minors’ Abortions in Mississippi.”  Family Planning Perspectives, 27(3), 120–2.

_____.  (1999).  “Unintended Pregnancy and Abortion:  A Public Health Perspective.”  Pp. 11–22 in Maureen Paul, et al., eds., A Clinician’s Guide to Medical and Surgical Abortion.  New York:  Churchill Livingstone.

Henshaw, Stanley K. & Lawrence B. Finer.  (2003).  “The Accessibility of Abortion Services in the United States, 2001.”  Perspectives on Sexual and Reproductive Health, 35(1), 16–24.

Hoyert, Donna L., et al.  (2006, April 19).  “Deaths:  Final Data for 2003.”  National Vital Statistics Reports, 54(13).  Hyattsville, MD:  National Center for Health Statistics.

Ingram, Roger, et al.  (2007, April).  Second-Trimester Abortions in England and Wales.  Southampton, UK:  Centre for Sexual Health Research.  [Online].

Partial-Birth Abortion Ban Act of 2003, S. 3, 108th Cong., 1st Sess.  (2003).  [Online].

Paul, Maureen, et al.  (1999).  A Clinician’s Guide to Medical and Surgical Abortion.  New York:  Churchill Livingstone.

Planned Parenthood of Central Missouri v. Danforth, 428 U.S. 52 (1976).

Roe v. Wade, 410 U.S. 113 (1973).

Saraiya, M., et al.  (1999).  “Spontaneous Abortion-Related Deaths Among Women in the United States, 1981-1991.”  Obstetrics and Gynecology, 94(2), 172–6.

Thornburgh v. American College of Obstetricians and Gynecologists, 476 U.S. 747 (1986).

Vestal, Christine.  (2007, April 30, accessed 2007, May 4).  “Abortion Ruling Sets New State Battle Lines.”  [Online].

Lead Author — John Mugge
Revised By — Deborah Golub, MPH

Published: 06.01.06 | Updated: 05.16.07

Published by the Katharine Dexter McCormick Library

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