Abortion after the First Trimester

Since the legalization of abortion throughout the U.S. in 1973, abortion services have become more widely accessible and knowledge of 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 activists seek to limit access to abortion through bans on postviability procedures, laws imposing a fixed date for fetal viability, and so-called "partial birth" abortion bans, which could limit access to abortion during all stages of pregnancy.

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 parental notification laws and mandatory delay laws. Also, by asserting their bias at a local level through the misapplication of zoning laws, etc., they create a climate so threatening 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 1990 and 1997, the number of abortions in the United States fell from 1,429,577 to 1,186,039 (CDC, 2000). The CDC estimates that 55 percent of legal abortions occur within the first eight weeks of gestation, and 88 percent are performed within the first 12 weeks. Only 1.4 percent occur after 20 weeks (CDC, 2000).

Since the 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, 1990).

Various Factors Require Women to Have Abortions after the First Trimester

Barriers to Service

Geographic A 1993 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, 1995a). It follows that having to travel such distances would cause delays in obtaining abortions.

Provider shortage As of 1996, 86 percent of U.S. counties have no known abortion provider; these counties are home to 32 percent of all women of reproductive age. Furthermore, 95 percent of non-metropolitan counties have no abortion services, and 87 percent of non-metropolitan women live in these unserved counties (Henshaw, 1998).

• Financial In 1993, the average cost of a first-trimester, non-hospital abortion with local anesthesia was $296. [The New York Times reports that this cost is currently about $350 (Talbot, 1999).] 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 escalates with gestational age: in 1993, non-hospital facilities charged $604 for abortion at 16 weeks gestation and $1,067 at 20 weeks (Henshaw, 1995a). For various reasons, most patients pay for abortions out-of-pocket. For example, in 1995, one-third of women did not have employer-based insurance; most states did not allow Medicaid funding for abortions; and one-third of private insurance plans did not cover abortion or covered it only for certain medical indications (Henshaw, 1995a). For some, these costs can pose significant barriers to access.

• Legal restrictions Causing additional delays are state laws such as those mandating parental consent or notification or court-authorized bypass for minors and those imposing 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, 1995b).

Medical indications may lead to abortion after 12 weeks. Conditions in which the woman’s health is threatened or aggravated by continuing her pregnancy include

• malignant hypertension
• out-of-control diabetes
• heart failure
• severe depression
• suicidal tendencies
• discovery of fetal anomalies incompatible with life, such as severe genetic disorders

Individual or Personal Reasons for Postponing Abortion Past 12 Weeks

• lack of financial and/or emotional support from the male partner
• fear of parents’ reaction when the pregnant person is an adolescent
• psychological denial of pregnancy, as may occur in cases of rape or incest
• lack of pregnancy symptoms, seeming continuation of "periods," irregular menses
• absence of partner due to estrangement or death (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 29 percent of all abortions performed after the first trimester (CDC, 2000).

Among women under age 15, one in four abortions is performed at 13 or more weeks gestation (CDC, 2000).

The very youngest women, those under age 15, are more likely than others to obtain abortions at 21 or more weeks gestation (CDC, 2000).

• 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 partner (Paul et al., 1999). In addition, adolescents may have irregular periods for up to 18 months after menarche (Friedman et al., 1998), making it difficult for them to detect pregnancy. Also, as previously noted, state laws requiring parental consent or court-authorized bypass for minors can cause delays.

Abortion after the First Trimester Is as Safe as Carrying a Pregnancy to Term

Overall, abortion has a low morbidity rate. Fewer than 1 percent of women who undergo legal abortion sustain a serious complication (AGI, 1998). The rate of complication increases by about 20 percent for each additional week of gestation past eight weeks (Paul et al., 1999).

• Presently the death rate from abortion at all stages of gestation is 0.6 per 100,000 procedures (Paul et al., 1999). The risk of death associated with childbirth is about 10 times as high as that associated with abortion (AGI, 1998).

• The risk of death associated with abortion increases with the length of pregnancy, from one death for every 530,000 abortions at eight or fewer weeks to one per 17,000 at 16–20 weeks, and one per 6,000 at 21 or more weeks (AGI, 1998). After 20 weeks gestation there is no statistically significant difference in maternal mortality rates between terminating a pregnancy by abortion and carrying it to term (Paul et al., 1999).

• The risk of death from abortion after the first trimester does not appear to be related to the type of procedure performed. Dilation and evacuation (D&E), the most common abortion procedure after the first trimester, has a mortality rate of 3.3 per 100,000 abortions. While labor induction abortion once had a higher mortality risk, the most recent data shows its mortality rates to be comparable to D&E (Paul et al., 1999).

Current Law Allows for 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 (AGI, 1997).

• In Planned Parenthood of Southeastern Pennsylvania v. Casey (505 U.S. 833 (1992)), the Supreme Court asserted that viability marks the point at which the state’s interest in the fetus becomes "compelling," although determination of viability hinges on the physician’s discretion (AGI, 1997). 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).

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 (AGI, 1997).

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 or fetal weights for determining viability.

• The court reaffirmed these rulings in the 1979 case Colautti v. Franklin (439 U.S. 379 (1979)) and also voided a section of a Pennsylvania statute requiring a doctor to abide by a prescribed standard of care if she or he determined that the fetus was or might be viable.

(AGI, 1997)

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 (Paul et al., 1999).

• In the same case, the court did permit states to regulate the licensing of facilities that provide abortions, so long as the regulations do not "unduly burden" women’s access to abortion (Paul et al., 1999; Harrison & Gilbert, 1993).

Legal Limitations on Abortion after the First Trimester

• In Thornburgh v. American College of Obstetricians and Gynecologists(476 U.S. 747 (1986)), the U.S Supreme Court ruled that a state may require that a second physician be present at the abortion of a viable fetus to care for it should it be born alive, but that requirement must be waivable in a medical emergency (Paul et al., 1999).

Laws and Specific Abortion Techniques

• In Thornburgh v. American College of Obstetricians and Gynecologists, 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 postviability abortion, a physician has the right to choose the method most likely to preserve the woman’s health, even if it might endanger fetal survival.

(AGI, 1997)

So-Called "Partial Birth" Abortion Is Not a Medical Term

• Seeking the enactment of "method bans," anti-choice activists have called for legislation prohibiting "partial birth" abortions, a political term that has no medical definition (Paul et al., 1999).

• In Stenberg v. Carhart (530 U.S. 914 (2000)), the U.S. Supreme Court ruled that Nebraska’s so-called "partial birth" abortion ban was unconstitutional because it failed to include an exception to preserve the health of the woman, and it imposed an undue burden on a woman’s ability to choose an abortion. The court determined that the law was so broadly worded that it could be used to prohibit access to the safest and most common medical procedures for terminating a pregnancy before fetal viability (CRLP, 2000).

• Bans on so-called "partial birth" abortions have been passed by 31 states, and legal challenges to these laws have been brought in 21 states. As the language used in most of these statutes is comparable to the Nebraska law struck down in Stenberg v. Carhart, these laws are invalid and unenforceable (CRLP, 2001).

References and Additional Information

AGI — Alan Guttmacher Institute. (1997, accessed 1999, July 16). Issues in Brief. Late-Term Abortions: Legal Considerations [Online]. http://www.agi-usa.org/pubs/ib13.html.

_____. (1998, accessed 1999, July 16). Facts in Brief: Induced Abortion [Online]. http://www.agi-usa.org/pubs/ib13.html.

CDC — Centers for Disease Control and Prevention. (2000, December 8). "Abortion Surveillance — United States, 1997."Morbidity and Mortality Weekly Report, 49(SS-11).

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

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

CRLP — Center for Reproductive Law and Policy. (2000, accessed 2001, March 22). ""Partial-Birth Abortion" Bans — Unconstitutional, Deceptive, Extreme."

_____. (2001, accessed 2001, March 22). ""Partial-Birth" Abortion Ban Legislation: By State."

Cunningham, F. Gary, et al. (1997). Williams Obstetrics, 20th ed. Stamford, CT: Appleton & Lange.

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

Gold, Rachel Benson. (1990). Abortion and Women's Health: A Turning Point for America? New York: The Alan Guttmacher Institute.

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. (1995a). "Factors Hindering Access to Abortion Services." Family Planning Perspectives, 27(2), 54–59 & 87.

_____. (1995b). "The Impact of Requirements for Parental Consent On Minors’ Abortions in Mississippi." Family Planning Perspectives, 27(3), 120–122.

_____. (1998). "Abortion Incidence and Services in the United States, 1995–1996." Family Planning Perspectives, 30(6), 263–270 & 287.

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).

Planned Parenthood of Southeastern Pennsylvania v. Casey, 505 U.S. 833 (1992).

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

Stenberg v. Carhart, 530 U.S. 914 (2000).

Talbot, Margaret. (1999, July 11). "The Little White Bombshell." New York Times Magazine, 39–43.

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

Courtesy Planned Parenthood Federation of America, Inc.