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 rst trimester of
pregnancy. For a number of reasons, however, abortion
after the rst trimester remains a necessary option for
some women.
Unfortunately, opponents of safe and legal abortion seek
to limit access through, among other means, laws imposing
a xed date for viability and bans that would outlaw safe,
medically appropriate abortions in the second trimester.
Their goal is to make all abortions illegal.
In fact, the same anti-women’s health activists who
would limit access to abortion after the rst trimester
also oppose access to abortion in the rst trimester by
advancing numerous restrictions, including parental
involvement laws and mandatory waiting period laws.
Also, by asserting their bias at a local level through
picketing doctors’ homes and ofces, health center
blockades, threats of violence against doctors, and the
misapplication of zoning laws, etc., these activists create
such a threatening climate that the number of qualied
providers is diminished. These actions endanger the
health of women and the right of physicians to determine
the most appropriate treatment for their patients.
The Number of Abortions After the First Trimester Is
Relatively Small
• In 2011, an estimated 1.1 million abortions were
performed, a 13 percent decline from 2008. The
abortion rate in 2011 was the lowest rate since 1973
(Jones and Jerman, 2014). The U.S. Centers for
Disease Control and Prevention (CDC) estimates
that 65 percent of legal abortions occur within the
rst eight weeks of gestation, and 91 percent are
performed within the rst 13 weeks. Only 1.4 percent
occur at or after 21 weeks (CDC, 2014).
• Since the nationwide legalization of abortion in 1973,
the proportion of abortions performed after the rst
trimester has decreased because of increased access
to and knowledge about safe, legal abortion (Gold,
2003).
• The number of abortions after the rst trimester
might be even smaller if women had greater access
to safe and legal abortion. Most women who’ve
had an abortion say they would have preferred to
have it earlier, but nancial limitations and/or lack of
knowledge about pregnancy caused them to delay
(Finer et al. 2006).
VARIOUS FACTORS REQUIRE WOMEN TO HAVE
ABORTIONS AFTER THE FIRST TRIMESTER
Barriers to Service
• Geographic — A 2005 survey of U.S. abortion
providers found that among women who have non-
hospital abortions, approximately 19 percent travel
50 to 100 miles for services, and an additional eight
percent travel more than 100 miles (Jones et al., 2008).
It follows that having to travel such distances can
cause delays in obtaining abortions.
• Provider shortage — As of 2011, 89 percent of U.S.
counties had no known abortion provider; these
counties are home to 38 percent of all women
of reproductive age. (Jones and Jerman, 2014).
Furthermore, in 2008, 97 percent of non-metropolitan
counties have no abortion services, and 92 percent
of non-metropolitan women live in these unserved
counties (Jones and Kooistra, 2011).
ABORTION AFTER THE FIRST TRIMESTER
in the United States
• Financial — In 2000, the average cost of a rst-
trimester, in-clinic, non-hospital abortion with local
anesthesia was $372 (Henshaw & Finer, 2003). In 2009
this cost was $451. The median cost of medication
abortion, which can be done in the rst 63 days of
pregnancy, was $490 (Jones and Kooistra, 2011).
For low-income and younger women, gathering
the necessary funds for the procedure often causes
delays. A recent study found that women at or under
100 percent of the federal poverty level were more
likely than women at higher income levels to have
second-trimester abortions (Jones and Finer, 2012).
Compounding the problem is the fact that the cost
of abortion rises with gestational age: in 2009, non-
hospital facilities charged an average of $1,500 for
abortion at 20 weeks (Jones and Kooistra, 2011). Most
women are forced to pay for abortions out-of-pocket.
In 2008, only 20 percent of abortions were paid by
Medicaid and another 12 percent were billed directly
to private insurance (Jones et al, 2010). For some
women, the cost of abortion can pose signicant
barriers to access. Thirty-six percent of women having
abortions in the second trimester reported that they
needed time to raise money to have the abortion. In
addition, 18 percent of women having abortions in the
second trimester reported that worries about the cost
of the procedure caused them to take more time to
make their decision (Finer, et al., 2006).
• Legal restrictions — Causing additional delays are
state laws that mandate parental consent, notication,
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 pregnancy may also
lead to abortion after 12 weeks.
• In a survey of U.S. women deciding to end their
pregnancies, signicantly more women in their second
trimester cited fetal health concerns than women
in their rst 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; and
• 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., 2009).
Other Reasons for Having an Abortion Past 12 Weeks
• Exposure to intimate partner violence.
• Absence of partner due to estrangement or death.
• Lack of nancial 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 (Jones and Finer, 2012; Ingram
et al., 2007; Paul et al., 2009).
Adolescents Often Delay Abortion Until After
the First Trimester
• Adolescents are more likely than older women to obtain
abortions later in pregnancy (Jones and Finer, 2012).
• Among women under age 15, one in ve abortions is
performed after 13 weeks’ gestation. Twelve percent
of teens aged 15 to 19 obtained an abortion after 13
weeks’ gestation (CDC, 2014).
• The very youngest women — those under age 15 — are
more likely than others to obtain abortions at 21 or
more weeks’ gestation (CDC, 2014).
• Common reasons why adolescents delay abortion
until after the rst 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., 2009). In
addition, adolescents may have irregular periods
(Friedman et al., 1998), making it difcult for them to
detect pregnancy. One study found that teens took
a week longer to suspect pregnancy than adults
did; teens also took more time to conrm their
pregnancies with a pregnancy test (Finer et al, 2006).
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. Less than
0.3 percent of women undergoing legal abortion
procedures at all gestational ages sustain a serious
complication requiring hospitalization (Boonstra et
al., 2006; Henshaw, 1999; Upadhyay, et al., 2015). The
rate of complication increases 38 percent for each
additional week of gestation beyond eight weeks
(Paul et al., 2009).
• 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 a
surgical abortion is about one per one million 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 14 times as high as that
associated with abortion (Raymond & Grimes, 2012).
• 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 2007 was 12.7 deaths per 100,000 live births — a
signicant difference in maternal mortality rates
between deciding to end a pregnancy by abortion or
carrying it to term (Paul et al., 2009; Xu et al., 2010).
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 personal decision to end a pregnancy. Only
after viability — being capable of sustained survival
outside the woman’s body with or without articial aid
— may the states ban abortion altogether. Abortions
necessary to preserve the woman’s life or health must
still be allowed, however, even after 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 deciding to have 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
xed gestational limits for determining viability. The
court reafrmed 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 Specic Abortion Techniques
• In Thornburgh v. American College of Obstetricians
and Gynecologists (476 U.S. 747 (1986)), the U.S.
Supreme Court ruled that a woman may not be
required to risk her health to save a pregnancy 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.
• On April 18, 2007, in Gonzales v. Carhart (550 U.S. 124
(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 5–4 decision, upheld the so-called
Partial-Birth Abortion Ban Act of 2003 (the “federal
abortion ban”) — the rst 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 rst trimester. 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 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 end a pregnancy, especially
after the rst trimester. This shift will likely spur state
efforts to enact new abortion restrictions. Indeed,
opponents of women’s health continue to work
tirelessly to chip away at or limit access for women.
The Guttmacher Institute released a report showing
that 231 provisions were passed in state legislatures
in the last four years to restrict access to abortion
(Nash et al., 2015).
Protecting the Right to Make Personal Medical
Decisions — 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 safe and legal
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 (FOCA), and other
states are seeking to pass similar legislation (Guttmacher
Institute, 2015). Although state-level FOCAs have no
impact on the federal abortion ban, such laws prohibit
the state government from interfering with the decision
to continue or end a pregnancy.
Cited References
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