Does Banning Abortions After 15 Weeks Make Any Sense?

Susan Wills, J.D., LL.M., Kathi Aultman, M.D.   

This is issue 68 of CLI’s On Point series. To view this report as a PDF see: Does Banning Abortions After 15 Weeks Make Any Sense?

 

 

Mississippi’s Gestational Age Act—banning almost all abortions after 15 weeks’ gestation—raises the question: “Why 15 weeks?”[1]

 

A person with pro-life convictions could reason that an abortion at six weeks’ gestation ends the life of a child just as surely as an abortion at 15 weeks, or from the moment of fertilization.

 

Someone who supports abortion might argue that Roe v. Wade established a woman’s right to terminate a pregnancy up until birth—under Doe v. Bolton’s “health” exception—if the mother is distressed due to the inconvenient timing or other circumstances of her pregnancy.[2]

 

And yet the choices, risks, and long-term consequences faced by a woman with an unplanned pregnancy differ significantly in the first trimester of pregnancy compared to those in the mid- and late trimesters. These very real and serious consequences seemingly never make it into the national discussion of abortion, to the detriment of the women who bear these burdens.

 

While still reeling from the shock of a positive pregnancy test, a woman may feel overwhelmed by the questions she has and the choices she is facing: single motherhood? marriage? adoption? Where can she go for advice or financial assistance during pregnancy and beyond? How would pregnancy and a child affect her education or career? Wouldn’t an abortion be the easiest way to resolve her dilemma?

 

The abortion industry and its advocates have been stunningly successful in promoting abortion as just that—the easiest way to resolve an unplanned pregnancy. They have accomplished this by obscuring the reality of what abortion entails: It is a “choice,” rather than paying a stranger to kill one’s child. The procedure, we are told, gently ends a “pregnancy,” not a human life. “Products of conception” or “pregnancy tissue” are expelled, not dead, dismembered children.

 

This paper will explore the different “choices” an abortion-minded pregnant woman has—in terms of abortion methods and risks to her own health—in the first trimester of pregnancy compared to methods and risks after 15 weeks. These differences fully justify Mississippi’s post-15-week ban.

 

The Two Choices of First-Trimester Abortion Methods: Surgical or Chemical

 

Surgical abortion: During an aspiration abortion, or Suction D&C, a flexible or rigid cannula, a plastic tube with a hole in the end, is inserted into the uterus, and the fetus and placenta are removed by mechanical suction. In early gestations, a manual vacuum aspirator (MVA) can be used. Mechanical dilation is necessary for most procedures.[3] Aspiration abortions are generally performed up through 14 weeks.[4] Within a couple of weeks of that time, the baby’s tissues become firmer and can’t be suctioned through the hole in the cannula.[5]

 

This is how Planned Parenthood (“PP”) describes the “in-clinic” (surgical) abortion of a developing human person in the first trimester:

 

A doctor or nurse uses medical instruments and gentle suction to remove the pregnancy [sic] from your uterus.[6]

 

In fact, there is nothing gentle about the procedure. According to Contraceptive Technology,[7] a metal “short-bladed speculum” is inserted into the birth canal to keep the walls of the vagina apart so the provider can see the cervix and pull it forward in order to inject an anesthetic in several areas of the cervix to reduce pain. He or she then clamps a tenaculum onto the cervix to “stabilize” it. A tenaculum “resembles a pair of scissors with sharp-pointed hooks at the end.”[8] One physician described it as a “butcher’s hook that can make holes in the cervix.”[9]

 

The tenaculum allows surgical instruments to enter the uterus to detach and remove the child and related tissues, but first the cervix needs to be dilated. Dilation in the first trimester can be accomplished either mechanically—enlarging the opening by inserting as many metal or plastic rods as are necessary to allow entry of a cannula into the womb—or by administering a prostaglandin three to four hours before the abortion procedure to soften the cervix. The abortion provider then moves the cannula (attached to an electric vacuum pump or an MVA) throughout the womb, detaching and sucking up parts of the child, the umbilical cord, and placenta.

In a YouTube video describing abortion procedures, Dr. Anthony Levatino,[10] who formerly performed abortions, explains that the electric vacuum aspiration machine has 10- to 20-times the suction power of a household vacuum. A curette is then used to scrape the uterine lining to remove any tissues that might have been missed.[11]

Most would not describe this process as gentle.

 

Complications and risks: Planned Parenthood concedes that there are immediate risks in even the earliest surgical abortions, but omits or denies others (e.g., increased risk of breast cancer,[12] pre-term births in subsequent pregnancies due to cervical incompetence and other abortion-related injuries,[13] and mental health problems including substance abuse).[14]  UpToDate, used by many practitioners to remain current, lists these risks: infection, including sepsis; hemorrhage, which may require transfusion; and uterine perforation, which may require surgical intervention.  Hematometra (the uterus becoming filled with blood clots), retained products of conception, and ongoing pregnancy may all require a repeat procedure.

 

UpToDate also lists seizures from local anesthetic, cervical stenosis (scarring of the cervical opening), and death. Warren Hern, in his textbook “Abortion Practice” also lists allergic reactions, vasovagal reactions, and cardiopulmonary arrest from local anesthesia and the risks of general anesthesia if used. He also includes postabortal depression, missed ectopic pregnancy, underestimation of gestational age, amenorrhea related to cervical stenosis or Asherman’s Syndrome, and Disseminated Intravascular Coagulopathy (DIC).[15] Planned Parenthood significantly downplays the risks as “really rare.[16] Studies based on record linkage of abortion history and subsequent emergency room visits/hospital admissions visits for abortion-associated physical complications show rates of up to 6%.[17] Considering that over 60 million abortions have been performed in the U.S. since 1973, the possibility that six percent (3,600,000) involve immediate adverse events, including deaths, is not inconsiderable.

 

Chemical abortion: The Centers for Disease Control and Prevention reported that in 2018 chemical abortions constituted almost 40 percent of all U.S. abortions.[18] Charlotte Lozier Institute’s review of the most current state data estimates the percentage at now near 44 percent.[19] The at-home “medication” (i.e., chemical) abortion is described by Planned Parenthood in this innocuous way:

 

You take pills that end your pregnancy and make your uterus expel the pregnancy tissue [sic] (like an early miscarriage).[20]

 

Typically, mifepristone (brand name Mifeprex)—the first pill—is administered in the clinic or doctor’s office (although now more likely at home after the Biden Administration’s Food and Drug Administration (FDA) relaxed enforcement of the in-person requirements of the Risk Evaluation and Mitigation Strategy [REMS] for the drug).[21] Mifepristone leads to the death of the embryo or fetus by blocking progesterone, causing the breakdown of the uterine lining and his/her supply of oxygen and nutrients from the mother. Misoprostol tablets are taken 24 to 48 hours later to induce strong uterine contractions to expel the dead child and placenta.[22] According to Dr. Levatino, contractions can last anywhere from a few hours to several days. Bleeding will typically continue for nine to 16 days, but in eight percent of chemical abortions bleeding may continue for over 30 days. In one percent, hospitalization will be required due to heavy bleeding.[23]

Complications and Risks: Incomplete abortion, retained placenta, ongoing pregnancy, infection, hemorrhage, missed ectopic pregnancy, and death. The risk of fatal complications increases with increasing gestational age, just as in aspiration abortions.[24]

 

Reported deaths and “adverse events” from chemical abortion are even higher than those from surgical abortion.[25] For example, a “Finnish record linkage study of more than 42,000 women published in 2009, and comparing chemical to surgical abortions, reported that complications were almost four times more frequent after chemical (20%) than surgical abortions (5.6%). Hemorrhage (15.6% vs 2.1%) and incomplete abortion (6.7% vs 1.6%) were the most common complications.”[26]

 

As of 2018, the FDA reported 24 deaths associated with chemical abortions and more than 4,000 adverse events.[27] It is important to note that adverse event reporting by medical personnel and patients to the FDA’s Adverse Event Reporting System (FAERS) is not mandatory except for those prescribing the drug, and since 2016 providers have only been required to report deaths. Thus, adverse events are vastly underreported. In 2000, the General Accounting Office estimated that only one to 10 percent of adverse events were reported to the FDA.[28] There is no medical coding for deaths associated with abortion, so many may go unreported. Confirmed deaths associated with chemical abortions have been attributed to infection, undiagnosed ectopic pregnancies, and hemorrhaging. With the recent relaxation of gestational age limits and allowing “no-test-chemical abortions” by mail, incomplete abortions, hemorrhage, and ectopic pregnancy-related deaths are likely to rise substantially.[29]

 

 

Lest We Forget …

Before delving into the gruesome choices faced by women considering abortion after their child has completed 15 weeks’ gestation—abortions which Mississippi seeks to ban—it would be well to remind ourselves what is at stake in every abortion.

 

No one does that better than Alexander Tsiaras. When he was Associate Professor of Medicine and Chief of Scientific Visualization at Yale University’s Department of Medicine,[30] Tsiaras worked with a Nobel Prize-winning pioneer in magnetic resonance imaging (MRI). In an engaging TEDTalk, Tsiaras presents excerpts of one project, “From Conception to Birth.”[31] Although the visualizations and narration of embryonic and fetal development in this TEDTalk skip from 12 weeks’ gestation to 8 months, followed by birth, Tsiaras leaves no doubt about the unimaginable complexity and beauty of human development in utero. The Endowment for Human Development, a well-respected organization dedicated to providing educational material on embryology and fetal development, provides actual videos of the fetus via Amnioscopy in which a camera is inserted into the cervix to visualize the fetus within the womb. They also provide ultrasound images including 4D sonography. Also, Live Action’s Olivia video is a beautiful animated depiction of fetal life.[32] Keep these videos in mind as our discussion turns to subjects such as the preferred techniques to tear off fetal limbs and crush or collapse the skulls of nearly-born infants by vacuuming out their brains in Dilation & Evacuation (D&E) and Intact D&E, otherwise known as “partial-birth abortion” or “D&X” procedures.[33]

 

Abortion Methods After 15 Weeks

In his dissenting opinion in Stenberg v. Carhart, 530 U.S. 914 (2000), Justice Clarence Thomas—quoting directly from testimony in lower courts, Congressional hearings, and briefs—explains three choices of abortion procedures performed after 15 weeks.

 

Dilation and Evacuation (D&E)

 

The primary form of abortion used at or after 16 weeks’ gestation is known as “dilation and evacuation” or “D&E.” … [citations omitted throughout] When performed during that stage of pregnancy, the D&E procedure requires the physician to dilate the woman’s cervix and then extract the fetus from her uterus with forceps. … Because of the fetus’ size at this stage, the physician generally removes the fetus by dismembering the fetus one piece at a time. … The doctor grabs a fetal extremity, such as an arm or a leg, with forceps and “pulls it through the cervical os … tearing … fetal parts from the fetal body … by means of traction.” …  In other words, the physician will grasp the fetal parts and “basically tear off pieces of the fetus and pull them out.” … The fetus will die from blood loss, either because the physician has separated the umbilical cord prior to beginning the procedure or because the fetus loses blood as its limbs are removed. … When all of the fetus’ limbs have been removed and only the head is left in utero, the physician will then collapse the skull and pull it through the cervical canal. … At the end of the procedure, the physician is left, in respondent’s words, with a “tray full of pieces.”[34]

 

Induction Abortion

 

Some abortions after the 15th week are performed using a method of abortion known as induction. … In an induction procedure, the amniotic sac is injected with an abortifacient such as a saline solution or a solution known as a “prostaglandin.” … Uterine contractions typically follow, causing the fetus to be expelled.[35]

(Amnioinfusion abortions using saline, urea, or prostaglandin PGF have generally been abandoned today in favor of induction abortions, commonly using misoprostol and mifepristone.[36] The drugs given for induction abortions cause the woman to go into labor and deliver the child, who may still be alive if the abortionist hasn’t taken steps to kill him or her before the induction. Misoprostol is also used to induce labor in wanted pregnancies.)[37]

 

Partial-birth abortion (“intact D&E” or D&X)

 

A third form of abortion for use during or after 16 weeks’ gestation is referred to by some medical professionals as “intact D&E.” There are two variations of this method, both of which require the physician to dilate the woman’s cervix. … The first variation is used only in vertex presentations, that is, when the fetal head is presented first. To perform a vertex-presentation intact D&E, the doctor will insert an instrument into the fetus’ skull while the fetus is still in utero and remove the brain and other intracranial contents. … When the fetal skull collapses, the physician will remove the fetus.

 

The second variation of intact D&E is the procedure commonly known as “partial-birth abortion.” … This procedure, which is used only rarely, is performed on mid- to late-second-trimester (and sometimes third-trimester) fetuses. Although there are variations, it is generally performed as follows: After dilating the cervix, the physician will grab the fetus by its feet and pull the fetal body out of the uterus into the vaginal cavity. … At this stage of development, the head is the largest part of the body. Assuming the physician has performed the dilation procedure correctly, the head will be held inside the uterus by the woman’s cervix. … While the fetus is stuck in this position, dangling partly out of the woman’s body, and just a few inches from a completed birth, the physician uses an instrument such as a pair of scissors to tear or perforate the skull. …  The physician will then either crush the skull or will use a vacuum to remove the brain and other intracranial contents from the fetal skull, collapse the fetus’ head and pull the fetus from the uterus.[38]

 

(Partial-birth abortions on living fetuses have been illegal since 2003 under Title 18 U.S. Code § 1531. Abortion providers get around this law by causing fetal death prior to performing the abortion. It is only illegal to perform this procedure on a living fetus.)[39]

 

Justice Kennedy offers additional context in his dissent to the Court’s Opinion in Stenberg v. Carhart:

 

[In a D&E abortion, the fetus] “dies just as a human adult or child would: It bleeds to death. … The fetus can be alive at the beginning of the dismemberment process and can survive for a time while its limbs are being torn off. … Dr. Carhart has observed fetal heartbeat via ultrasound ‘with extensive parts of the fetus removed,’ … and testified that mere dismemberment of a limb does not always cause death because he knows of a physician who removed the arm of a fetus only to have the fetus go on to be born ‘as a living child with one arm.’”[40]

 

In the same dissent, Justice Kennedy amplifies Justice Thomas’s description of the partial-birth abortion (D&X) procedure:

 

In the D&X, the abortionist initiates the woman’s natural delivery process by causing the cervix of the woman to be dilated, sometimes over a sequence of days. … The fetus’ arms and legs are delivered outside the uterus while the fetus is alive; witnesses to the procedure report seeing the body of the fetus moving outside the woman’s body. … At this point, the abortion procedure has the appearance of a live birth. … With only the head of the fetus remaining in utero, the abortionist tears open the skull. … Witnesses report observing the portion of the fetus outside the woman react to the skull penetration.[41]

 

One such witness, Nurse Brenda Pratt Shafer, reported what she observed in testimony before the United States Senate Judiciary Committee. (H.R.1833 Hearing 18) Justice Thomas quotes a part of her testimony in his dissent:

 

The baby’s little fingers were clasping and unclasping, and his little feet were kicking. The doctor stuck the scissors in the back of his head, and the baby’s arms jerked out, like a startle reaction, like a flinch, like a baby does when he thinks he is going to fall.

 

The doctor opened up the scissors, stuck a high-powered suction tube into the opening, and sucked the baby’s brains out. Now the baby went completely limp.[42]

 

Not to belabor the point, but by 2007 when the Supreme Court decided Gonzales v. Carhart—upholding the Congressional ban on partial-birth abortion—“the procedure had evolved,” according to Justice Kennedy who authored the Opinion of the Court:

 

Another doctor, for example, squeezes the skull after it has been pierced “so that enough brain tissue exudes to allow the head to pass through.” … Still other physicians reach into the cervix with their forceps and crush the fetus’ skull. … Others continue to pull the fetus out of the woman until it disarticulates at the neck, in effect decapitating it. These doctors then grasp the head with forceps, crush it, and remove it.[43]

 

Lastly, induction abortions on viable babies (after 23 weeks’ gestation) are generally performed in a hospital setting. Cervical dilation with the seaweed laminaria may take one to two days. Some abortionists inject digoxin or KCl to kill the baby before the induction so he or she won’t be born alive;[44] however, some tissue banks that supply aborted-baby parts for experiments discourage the use of digoxin to get “better” quality tissue and organs.[45]

 

When a mother’s or child’s life or health is endangered by continuing the pregnancy in later trimesters—e.g., from pre-eclampsia, placenta previa, or placental abruption—doctors normally perform a cesarian section or an induction to deliver the child early.[46] Some babies may inadvertently die from prematurity, but there is no medical reason to kill the child directly in order to save the mother’s life. An abortion would not normally be performed in an emergency because of the number of days required to dilate the cervix.

 

Risks and Complications: Complication rates, including death, increase with increasing gestational age. The risk of death from surgical abortion increases roughly 38 percent per week of gestation after 8 weeks.[47]

 

D&E and Intact D&E (D&X): Complications include retained products of conception, infection, hemorrhage, cervical laceration, uterine perforation, and death.[48] Injury to adjacent organs is more likely with perforation during D&E than during aspiration abortion and may involve damage to the bowel, bladder, or large vessels. Cervical insufficiency: Some studies found an increased risk of cervical insufficiency with rapid mechanical dilation and an increased number of abortions, which can lead to early pregnancy loss.[49] An ACOG Practice Bulletin also includes uterine atony, Disseminated Intravascular Coagulation (DIC), pulmonary embolism and amniotic fluid embolism as risks of  second-trimester abortions.[50] According to UpToDate, the “strongest risk factor for surgical abortion-related mortality is increasing gestational age.”[51]

 

Induction (medication) abortion: Complications include incomplete abortion, retained placenta, uterine rupture, cervical laceration, infection, hemorrhage, DIC, pulmonary embolism, amniotic fluid embolism, and death.[52]

 

David Reardon and John M. Thorp summarize various risks gleaned from 68 record linkage studies (and thus free of researcher/author bias) as follows:

 

Compared to women who deliver, those who miscarry or have TOP [termination of pregnancy] face significantly elevated rates of psychiatric disorders, substance use, suicidal behaviors, sleep disorders, post-traumatic stress disorders, a decline in general health, and elevated rates of recourse to medical treatments in general, most of which have been observed within the first through ten years following the pregnancy loss. [endnotes omitted][53]

 

Pre-Term Births: Numerous studies reviewed by Dr. Thorp have documented increased risks of complications from early and later-term abortions. The growing number of pre-term births (PTB) in the U.S.—now more than one in 10 U.S. births—and the fact that PTB is the primary cause of infant death and disability should be reason enough for alarm. Mechanical trauma from sharp instruments, bone fragments, lacerations, perforations, cervical injuries, and uterine scarring only increase with gestational age and can result in subsequent pre-term births.[54]

 

Mental Health Concerns: The literature on mental health problems associated with abortion has been marked by a significant level of author bias. Record linkage studies examined by Reardon and Thorp show a significantly higher recourse to mental health treatments after abortion.[55] Reardon and Christopher Craver similarly found a higher recourse to mental health treatments after a full-term birth following an abortion.[56]

 

The record linkage studies also consistently demonstrate higher rates of mortality among women who have undergone an abortion or had a miscarriage compared to the general population of women and compared to those who completed a first pregnancy. They summarize results thus:

 

Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk-taking behaviors.[57]

 

A seminal record linkage study by Mika Gissler et al. examined suicides after pregnancy in Finland between 1987 and 1994.[58] The authors reported that the mean annual suicide rate was 11.3/100,000 among women of reproductive age, but significantly lower among women who had given birth (5.9). The rate for women who had experienced a miscarriage was far higher (18.1) compared to those who gave birth, but an astonishing 34.7 per 100,000 among those who had undergone an abortion. Thus, while giving birth had a marked protective effect compared to all women of reproductive age, those who aborted a child were three times more likely to commit suicide compared to women of reproductive age generally and almost six times more likely to commit suicide compared to those who had given birth.

 

A 2012 study by Reardon and Coleman looked at records of all women in Denmark (463,473 women) who had their first pregnancy between 1980 and 2004 and who later died (2,238) to determine if mortality rates differed among those who had given birth, had a miscarriage or an induced abortion.[59] They found that, compared to women who had delivered, the risk of death for women who had a first-trimester abortion was “significantly higher for all periods examined, from 180 days (OR=1.84) … through 10 years (1.39).” The risk of death among those who had an abortion after 12 weeks’ gestation, was higher still: within the first year post-abortion (OR=4.31) through 10 years post-abortion (2.41).

 

Conclusion:

 

  • Aspiration abortions are generally not done after 15 weeks’ gestation. Abortions performed after 15 weeks’ gestation pose significantly greater immediate and long-term risks to women’s physical and mental health compared to first trimester abortions.
  • Because of the higher incidence of cervical injury caused by the need for increased cervical dilation, mid and late-trimester abortions endanger the lives and health of children subsequently conceived by subjecting them to an increased risk of miscarriage from cervical incompetence and a higher risk of pre-term birth.
  • Developing children—who are capable of feeling pain—should never be subjected to nontherapeutic and, frankly, barbaric procedures to tear off their limbs and end their lives in a manner that no humane person would use on a living creature.
  • The moral and spiritual impact of engaging in these gruesome procedures—especially for a person who took an oath to “First, do no harm”—is simply incalculable.
  • Mississippi’s post-15-week abortion ban is a rational and necessary first step that curbs the extremism of America’s current abortion practices.
  • Most Americans oppose abortion later in pregnancy (65% in second trimester and 80% in third trimester) with 76% supporting significant limits on abortion.[60] More and more Americans are coming to understand the life of unborn children based on modern science, and support protecting those unborn children.

 

 

Susan Wills, J.D. and Kathi Aultman, M.D. are associate scholars of the Charlotte Lozier Institute.

 

 

[1] Mississippi’s Gestational Age Act, MS Code § 41-41-191 (2019), https://law.justia.com/codes/mississippi/2019/title-41/chapter-41/gestational-age-act/section-41-41-191/.

[2] Doe v. Bolton, 410 U.S. 179 (1972), https://www.law.cornell.edu/supremecourt/text/410/179.

[3] Grace Shih and Robin Wallace, “First-trimester pregnancy termination: Uterine aspiration,” ed. Jody Steinauer, UpToDate (June 17, 2021), https://www.uptodate.com/contents/first-trimester-pregnancy-termination-uterine-aspiration/print?search=1st%20trimester%20abortion&topicRef=3296&source=see_link.

[4] Shih and Wallace, “First-trimester pregnancy termination.”

[5] Nathalie Kapp and Patricia Lohr, “Modern methods to induce abortion: Safety, efficacy and choice,” Best Practice & Research Clinical Obstetrics & Gynaecology 63 (Feb. 2020), 37-44, https://doi.org/10.1016/j.bpobgyn.2019.11.008.

[6] “What Facts About Abortion Do I Need to Know?” Planned Parenthood, Planned Parenthood Federation of America, http://web.archive.org/web/20210909203501/https://www.plannedparenthood.org/learn/abortion/considering-abortion/what-facts-about-abortion-do-i-need-know. Archived web page.

[7] Robert A. Hatcher et al., Contraceptive Technology. (New York 2018), 802 et seq.

[8] “Tenaculum: For Over 100 Years Women Have Endured Pain in Gynecology,” Aspivix, https://www.aspivix.com/tenaculum-for-over-100-years-women-have-endured-pain-in-gynecology/.

[9] “Tenaculum,” Aspivix.

[10] Dr. Levatino is a practicing OB-GYN who performed over 1,200 abortions early in his career. A moment of clarity when he was reassembling pieces of the head, limbs and torso of a child he had just aborted—to ensure that nothing remained in utero—prompted a change of heart. He stopped doing abortions and became a leading advocate for the unborn and their mothers.

[11] Anthony Levatino, “Abortion Procedures: 1st, 2nd, and 3rd Trimesters,” Youtube, uploaded by Live Action (Feb. 24, 2016), https://www.youtube.com/watch?v=CFZDhM5Gwhk.

[12] “How safe is an in-clinic abortion?” Planned Parenthood, Planned Parenthood Federation of America, https://www.plannedparenthood.org/learn/abortion/in-clinic-abortion-procedures/how-safe-is-an-in-clinic-abortion; “New England Journal of Medicine Recognizes Abortion – Breast Cancer Link,” Abortion Breast Cancer, https://www.abortionbreastcancer.com/news/new-england-journal-medicine-recognizes-abortion-breast-cancer-link.

[13] Byron C. Calhoun and Moira Gaul, “Induced Abortion and Subsequent Preterm Birth: Evidence of Risk Association,” presented at U.S. Surgeon General’s Conference on the Prevention of Preterm Birth (June 16-17, 2008), https://downloads.frc.org/EF/EF08L36.pdf.

[14] “Abortion Contributes to Mental Health Problems: Both Sides Agree According to a Comprehensive Medical Review,” AfterAbortion.org, Elliot Institute, https://afterabortion.org/abortion-contributes-to-mental-health-problems-both-sides-agree-according-to-a-comprehensive-medical-review/; Priscilla Coleman, “Abortion and mental health: quantitative synthesis and analysis of research published 1995–2009,” British Journal of Psychiatry 199 (Sep. 2011), 180-186, doi:10.1192/bjp.bp.110.077230; Shih and Wallace, “First-Trimester Pregnancy Termination.”

[15] Warren Hern, “Management of Complications” in Abortion Practice (Philadelphia 1984), 175-187.

[16] “How Safe is an In-Clinic Abortion?” Planned Parenthood.

[17] “Short Term Complications and Other Aspects of Morbidity,” AbortionRisks.org, https://abortionrisks.org/index.php?title=Short_Term_Complications_and_Other_Aspects_of_Morbidity.

[18] “Reproductive Health: Data and Statistics,” CDC, U.S. Department of Health & Human Services, https://www.cdc.gov/reproductivehealth/data_stats/index.htm.

[19] Tessa Longbons, “U.S. Abortion Trends: 2019 and Preliminary 2020,” American Reports Series 19, Charlotte Lozier Institute (Sep. 10, 2021), https://s27589.pcdn.co/wp-content/uploads/2021/09/American-Report-Series_19.pdf.

[20]  “What Facts About Abortion Do I Need to Know?” Planned Parenthood.

[21] Janet Woodcock, “CDER Review Results,” received by Maureen Phipps and William Grobman (Apr. 12, 2021), https://www.sba-list.org/wp-content/uploads/2021/04/govdoc20210412-226601.pdf; “FDA Decision to Relax Chemical Abortion Rule Ignores the Science, Neglects Women, Places Them in Danger,“ Charlotte Lozier Institute  (Apr. 13, 2021), https://lozierinstitute.org/fda-decision-to-relax-chemical-abortion-rule-ignores-the-science-neglects-women-places-them-in-danger/; Kate Smith, “Biden administration to lift abortion pill restriction amid pandemic,” CBS News (Apr. 13, 2021), https://www.cbsnews.com/news/abortion-pill-restrictions-lifted-pandemic-fda/.

[22] George Delgado et al., “A Case Series Detailing the Successful Reversal of the Effects of Mifepristone Using Progesterone,” Issues in Law & Medicine 33 (2018), https://pwhcenters.org/wp-content/uploads/2018/04/ABPillReversal_CDM_040618.pdf#:~:text=By%20blocking%20progesterone%20receptors%2C%20mifepristone%20leads%20to%20the,mifepristone%20decreases%20progesterone%20secretion%20by%20the%20corpus%20luteum.12.

[23] Levatino, “Abortion Procedures.”

[24] Shih and Wallace, “First-trimester pregnancy termination.”

[25] Jody Steinauer, “Overview of pregnancy termination,” ed. Robert L. Barbieri, UpToDate (Jan 5, 2021), https://www.uptodate.com/contents/overview-of-pregnancy-termination/print?sectionName=First%20trimester&search=1st%20trimester%20abortion&topicRef=3287&anchor=H3815503277&source=see_link.

[26] Ingrid Skop, “The ‘No-Test Medication Abortion’ Protocol: Experimenting with Women’s Health,” On Point Series 49, Charlotte Lozier Institute (July 30, 2020), https://lozierinstitute.org/the-no-test-medication-abortion-protocol-experimenting-with-womens-health/; See Maarit Niinimäki, et al., “Immediate Complications After Medical Compared With Surgical Termination of Pregnancy,” Obstetrics & Gynecology 114 (Oct. 2009), 795-804, doi: 10.1097/AOG.0b013e3181b5ccf9.

[27] “Mifepristone U.S. Post-Marketing Adverse Events Summary through 12/31/2018,” FDA, https://www.fda.gov/media/112118/download.

[28] “Testimony before the Subcommittees on Health and Environment, and Oversight and Investigations, Committee on Commerce, and Subcommittee on Health, Committee on Veterans’ Affairs, House of Representative: Adverse Events: Surveillance Systems for Adverse Events and Medical Errors, Statement of Janet Henrich,” U.S. General Accounting Office, February 2000. https://www.gao.gov/assets/t-hehs-00-61.pdf; Christopher Gacek, “RU-486 (Mifepristone) Side-Effects, 2000-2012,” Family Research Council, May 2012. https://downloads.frc.org/EF/EF12F08.pdf; “Prepared Statement of Diane E. Thompson,” Building A 21st Century FDA: Proposals to Improve Drug Safety and Innovation, Hearing of the Committee on Health, Education, Labor, and Pensions, United States Senate,“ Nov 2006. https://www.congress.gov/109/chrg/CHRG-109shrg31621/CHRG-109shrg31621.pdf, p. 29.

[29] Skop, “The ‘No-Test Medication Abortion’ Protocol.”

[30] A mathematician, computer programmer, photographer, artist, and entrepreneur, Tsiaras also invented a lens for an endoscope that can photograph the developing embryo and fetus from outside the amniotic sac.

[31] Alexander Tsiaras, “Conception to birth — visualized | Alexander Tsiaras,” Youtube, uploaded by TED (Nov. 14, 2011), https://www.youtube.com/watch?v=fKyljukBE70.

[32] The Endowment for Human Development, https://www.ehd.org/; “Baby Olivia,” Live Action. https://babyolivia.liveaction.org/.

[33] Tsiaras, “Conception to birth — visualized | Alexander Tsiaras.”

[34] Stenberg v. Carhart (Thomas, J. dissenting), 530 U. S. ____ (2000), https://www.law.cornell.edu/supct/pdf/99-830P.ZD3.

[35] Stenberg v. Carhart (Thomas, J. dissenting).

[37] GJ Hofmeyr et al.,  “Misoprostol for induction of labour: a systematic review,” Br J Obstet Gynaecol 106 (Aug. 1999),  doi: 10.1111/j.1471-0528.1999.tb08400.x. PMID: 10453829.

[38] Stenberg v. Carhart (Thomas, J. dissenting).

[39] Bonnie Scott Jones and Jennifer Dalven, “Abortion Law and Policy in the USA” in Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, ed. Maureen Paul et al. (2009); Anna K. Sfakianaki et al. “Induced fetal demise,” ed. Jody Steinauer, UpToDate (Aug. 19, 2021), https://www.uptodate.com/contents/induced-fetal-demise#H1.

[40] Stenberg v. Carhart (Kennedy, J. dissenting), 530 U. S. ____ (2000), https://www.law.cornell.edu/supct/pdf/99-830P.ZD3.

[41] Stenberg v. Carhart (Kennedy, J. dissenting).

[42] Ibid.

[43] Gonzales v. Carhart (Opinion of the Court), 550 U. S. ____ (2007), https://www.law.cornell.edu/supct/pdf/05-380P.ZO.

[46] “Impact on Pregnancies: Placenta Previa/Aburuptio Placentae/Retained Placenta,” AbortionRisks.org, https://abortionrisks.org/index.php?title=Impact_on_Later_Pregnancies#Placenta_Previa.2FAburuptio_Placentae.2FRetained_Placenta.

[47] Hammond, “Second-trimester pregnancy termination.”

[48] Ibid.

[49] Gabriele Saccone, Lisa Perriera, Vincenzo Berghella, “Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis,” American Journal of Obstetrics and Gynecology 214 (2016), 5: 572-591, https://doi.org/10.1016/j.ajog.2015.12.044; Liao, H., Wei, Q., Duan, L. et al. Repeated medical abortions and the risk of preterm birth in the subsequent pregnancy. Arch Gynecol Obstet 284579–586 (2011). https://doi.org/10.1007/s00404-010-1723-7; The American College of Obstetricians and Gynecologists, “Cerclage for the Management of Cervical Insufficiency,” Practice Bulletin 142 (Feb. 2014), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2014/02/cerclage-for-the-management-of-cervical-insufficiency. The data confirming these associations is inconsistent; “Research on Abortion and Preterm Birth,” Prevent Preterm, https://131b55a5-b29d-e372-83d1-9769982e3b82.filesusr.com/ugd/523623_f962f05bef524b79ab72e5f69c9409d7.pdf; Justin Diedrich and Jody Steinauer, “Complications of Surgical Abortion,” Clinical Obstetrics and Gynecology 52 (June 2009), 205-212, doi: 10.1097/GRF.0b013e3181a2b756; A. Molin, “Risk of Damage to the Cervix by Dilatation for First-Trimester-Induced Abortion by Suction Aspiration,” Gynecol Obstet Invest 35 (1993), 152-154, https://doi.org/10.1159/000292688; L.K. Dhaliwal, K.R. Gupta, and S. Gopalan, “Induced abortion and subsequent pregnancy outcome,” Journal of Family Welfare 49 (2003).

[50] The American College of Obstetricians and Gynecologists, “Second-Trimester Abortion,” Practice Bulletin 135 (June 2013), https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/06/second-trimester-abortion.  Note that this document does not break down these risks into D&E and induction specifically, but lists these risks for 2nd trimester abortions in general.

[51] Cassing Hammond, “Second-trimester pregnancy termination: Dilation and evacuation,” ed. Jody Steinauer, UptoDate (July 14, 2020), https://www.uptodate.com/contents/second-trimester-pregnancy-termination-dilation-and-evacuation/print.

[53] David C. Reardon and John M. Thorp, “Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis,” SAGE Open Medicine 5 (Nov. 13, 2017), https://doi.org/10.1177/2050312117740490.

[54] John M. Thorp, “Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later,” Hindawi 2012 (Dec. 13, 2012), https://doi.org/10.6064/2012/980812.

[55] David C. Reardon, “The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities,” SAGE Open Medicine 6 (Oct. 29, 2018), doi:10.1177/2050312118807624.

[56] David C. Reardon and Christopher Craver, “Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study,” Int J Environ Res Public Health 18 (Feb. 13, 2021), doi: 10.3390/ijerph18042179.

[57] Reardon and Craven, “Effects of Pregnancy Loss.”

[58] Mika Gissler et al., “Suicides after pregnancy in Finland, 1987–94: register linkage study,” BMJ 313 (Oct. 2, 1996), 1431, doi:10.1136/bmj.313.7070.1431.

[59] David C. Reardon and Priscilla Coleman, “Short and long term mortality rates associated with first pregnancy outcome: population register based study for Denmark 1980-2004,” Med Sci Monit. 18 (Sep. 1, 2012), doi: 10.12659/MSM.883338.

[60] David Crary, Hannah Fingerhut, “AP-NORC poll: Most say restrict abortion after 1st trimester,“(Jun 2021).  https://apnews.com/article/only-on-ap-us-supreme-court-abortion-religion-health-2c569aa7934233af8e00bef4520a8fa8; “Americans’ Opinions on Abortion” (January 2021), Knights of Columbus Marist Poll,  https://www.kofc.org/en/resources/news-room/polls/kofc-americans-opinions-on-abortion012021.pdf; See also https://www.sba-list.org/polling#late-term

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