This is Issue 10 of the On Point Series.
Introduction
Of interest to the medical, moral, sociological, and political issues surrounding late-term abortion is the question of why women seek abortion after 20 weeks gestation. Any data considered to answer this question must be examined carefully for limitations. However, a greater understanding of the reasons why women choose these late-term procedures is valuable to those who seek to offer alternative, compassionate options.
The Reality of Late-Term Abortion Procedures
Abortions performed after 20 weeks gestation, when not done by induction of labor (which leads to fetal death due to prematurity), are most commonly performed by dilation and evacuation (D & E) procedures.[1] These particularly gruesome surgical techniques involve crushing, dismemberment and removal of a fetal body from a woman’s uterus, mere weeks before, or even after, the fetus reaches a developmental age of potential viability outside the mother.[2] In some cases, especially when the fetus is past the stage of viability, the abortion may involve administration of a lethal injection into the fetal heart in utero to ensure that the fetus is not pulled out alive or with the ability to survive.
Late-term abortion is not an exact medical term, but it has been used at times to refer to surgical dilation & evacuation (dismemberment) abortions as well as intact dilation & extraction (partial-birth) abortions performed in the second (13-27 weeks) and third (27-39 weeks) trimesters. The graphic, unpalatable nature of abortion procedures performed on fetuses of such advanced gestation raises many objections, even among parties who might support abortion at earlier stages.[3] For these reasons, and because of the increased short-term health risks of these procedures for women,[4] numerous states have considered limiting late-term abortion procedures after 20 weeks gestation.[5] The actual number of surgical abortions performed after 20 weeks in the United States cannot be known due to a lack of national reporting.[6] CDC projections, based largely on voluntary state reporting and abortion provider survey data from the Guttmacher Institute, a former affiliate of Planned Parenthood, estimate that roughly 1%, or over 15,000, abortions are performed after 20 weeks annually in the U.S.[7] Thus, advocates of the women and unborn children affected by these procedures take great interest in mitigating the circumstances that drive women to seek late-term abortions.
For many years, abortion-rights advocates have asserted that abortions after 20 weeks are performed because of maternal health complications or lethal fetal anomalies discovered late in pregnancy.[8] However, wider data from both the medical literature and late-term abortion providers indicates that most late-term procedures are not performed for these reasons. Previous survey studies of late-term abortion patients have confirmed that most late-term abortions are performed because of a delay in pregnancy diagnosis and for reasons similar to those given by first-trimester abortion patients: financial stressors, relationship problems, education concerns or parenting challenges.[9]
A recent paper entitled, “Who seeks abortion at or after 20 weeks?” supports these conclusions.[10] The study, published in Perspectives on Sexual and Reproductive Health, a journal of the Guttmacher Institute, marks a notable departure from previous statements by abortion rights advocates that late-term abortions were rarely elective. Authors Foster and Kimport highlight the characteristics of women seeking abortion at or after 20 weeks gestation. The authors acknowledge that, in fact, wider “data suggests that most women seeking later terminations are not doing so for reasons of fetal anomaly or life endangerment.”[11] The study explores reasons for delay in seeking abortion services, comparing first-trimester and late-term abortion groups. While there are numerous limitations to the study, the authors suggest that the characteristics of women who seek both first-trimester and late-term abortions are substantially similar.
Who Seeks Late-term Abortion?
To explore the characteristics of women who choose abortion after 20 weeks of pregnancy, Foster and Kimport used data from a larger abortion study, currently being conducted at the University of California, San Francisco. Interview and questionnaire data from over 400 women were gathered from 16 facilities that offer abortion procedures after 20 weeks gestation. A significant limiting factor of the study is the fact that the authors excluded women who sought abortion for reasons of fetal anomaly or life endangerment, without commenting on how large of a cohort this represented. Another significant limiting factor of the study is that only 44% of the eligible women participated (eligibility defined as women who obtained an abortion after 20 weeks gestation for reasons other than life endangerment or fetal anomaly), leaving room for significant selection bias.[12]
Of the patients interviewed, 272 had received an abortion at or after 20 weeks, while 169 had received a first-trimester abortion. The authors noted that the sample of participating women was “similar in race and ethnicity, age and parity to [the] population of women who receive abortions nationally.” Sixty-nine percent of the study participants were non-white. Women were grouped and compared according to those who had received first-trimester abortions and those who received abortions at or after 20 weeks. Interviews and questionnaires were completed with all women one week after their abortion procedures.
The characteristics of women who sought abortions after 20 weeks were generally similar to those who received first-trimester procedures. “The two groups did not differ by race or ethnicity, number of live births or abortions, mental or physical health history or substance abuse,” write the study authors. Nearly identical majorities of women from both groups were unmarried. Identical majorities from both groups had more than one previous live birth. Only small minorities of women in both groups reported heavy drinking, recreational drug use or a history of depression. [13]
The only statistically significant demographic differences between the first-trimester and late-term abortion recipients were age and employment. Seventy-five percent of women from both groups were between ages 20 and 34. However, women ages 20-24 were found more likely than women ages 25-34 to seek late-term abortions. Unemployed women were more likely to seek late-term abortions than employed women. However, among those women who sought a late-term abortion, equal numbers were employed and unemployed. Not surprisingly, women who sought later abortions were more likely than their first-trimester counterparts to have discovered their pregnancy after eight weeks. Yet, a sizeable percentage within the late-term abortion group, nearly 40%, reported that they knew about their pregnancy prior to eight weeks of gestation.[14]
The study results also showed that, on average, women who obtained later abortions took twice as long as their first-trimester counterparts to obtain an abortion after discovering they were pregnant. Among women who received late-term abortions, the average time between pregnancy discovery and obtaining the abortion was over three months (14 weeks). Women receiving first-trimester abortions averaged a period of seven weeks between the time of pregnancy discovery and the time of their abortion. [15] The above results raise obvious questions as to why the timetable for obtaining an abortion was so much longer for women choosing late-term abortions.
As part of the study, participants were asked questions aimed at identifying possible reasons for delay in obtaining their abortion after discovering their pregnancy. The answers from both groups suggest that women share similar reasons for delaying abortion regardless of the gestational age at which they have the procedure. The majority of women in both groups gave at least one reason for delaying their abortion. Both groups cited the same seven reasons for delaying. Women in both groups reported “not knowing about the pregnancy,” “trouble deciding about the abortion,” and “disagreeing about the abortion with the man involved” with similar frequency.[16]
Among women in the late-term abortion group, the most commonly cited reason for delaying the procedure was “raising money for the procedure and related costs.” Two thirds of women in the late-term abortion group gave this reason, compared with one-third of the women in the first-trimester group. It is worth noting that the average prices paid by women in the study were $2,014 for a late-term abortion compared to $519 for a first-trimester abortion, suggesting that, paradoxically, delaying for financial reasons required significantly more finances in the end. Women who received late-term abortions also cited “difficulty securing insurance coverage,” “difficulty getting to the abortion facility,” and “not knowing where to go for an abortion” as delaying reasons more often when compared to the first-trimester group. However, the two groups gave similar answers when asked how many abortion facilities they contacted before finding one willing to perform their abortion: the first-trimester group called an average of 1.7 facilities and the late-term group called a similar average of 2.2 facilities.[17]
Conclusions
Abortion rights advocates have long insisted that late-term abortions are performed only in dire circumstances involving threats to a mother’s life or in cases of severe fetal anomaly. However, the above study, despite its limitations, suggests otherwise. The characteristic similarities and delay commonalities observed across first trimester and late-term abortion groups suggest that women who seek abortion share similar characteristics across gestational ages. The stressful circumstances of unprepared pregnancy, single-motherhood, financial pressure and relationship discord are primary concerns that must be addressed for these women. However, these circumstances are not fundamentally alleviated or ameliorated by late-term abortion. Indeed, late-term abortion places these women at greater risk of surgical complications, subsequent preterm birth, and mental health problems, while simultaneously ending the life of an unborn child.[18] As a medical profession and society, we rightly seek alternative, compassionate responses for the women seeking late-term abortion procedures for such challenging yet elective reasons.
Elizabeth Ann M. Johnson, M.D. is an Associate Scholar for the Charlotte Lozier Institute. Johnson received her A.B. cum laude from Princeton University in public policy, and her M.D. from the University of Minnesota Medical School. She is currently a fellow in the Program for Human Rights and Health at the University of Minnesota School of Public Health.
[1] Dilation and evacuation procedures are used for 96% of abortions performed at >13 weeks gestation in the United States. Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgical versus medical methods for second trimester induced abortion. Cochrane Database of Systematic Reviews. 2008; Issue 1, Art. No.: CD006714.
[2] The survival of very preterm infants has improved substantially in the past two decades, such that the gestational age at which at least half of very preterm infants survive has decreased to 23 weeks. Seri I, Evans J. Limits of viability: definition of the gray zone. J Perinatol. 2008;28(Suppl 1):S4–8.
[3] A recent study by the Lozier Institute examined gestational limits in 198 countries where abortion is legal; of those countries, only seven, including the United States, permit elective abortion after 20 weeks.
[4] Abortions performed after the first trimester have long been recognized to account for a disproportionate amount of abortion-related morbidity and mortality. Similar to other elective surgical or medical procedures, abortion procedures carry inherent risks of infection, bleeding, and damage to other genitourinary and gastrointestinal organs. They carry additional risks of incomplete emptying of the uterus, cervical laceration, and uterine perforation by the suction cannula or sharp curette. Additionally, abortions performed at later gestations are associated with higher odds of a subsequent preterm birth.
See: Lohr et al., 2008; Bartlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S, Atrash HK. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 2004; 103(4):729-737; Hammond C, Recent advances in second trimester abortion: an evidence-based review. Am J Obstet Gynecol. 2009;200(4):347-356; Diedrich J, Steinauer J. Complications of Surgical Abortion. Clin Obstet Gynecol. 2009;52(2):205-212; Shah PS, Zao J. Induced termination of prepregnancy and low birthweight and preterm birth: a systemic review and meta-analysis. Brit J Obstet Gynecol. 2009;116(11):1425-1442.
[5] Jones RK, Jerman J. Abortion incidence and service availability in the United States. 2011. Perspectives Sexual Repro Hlth. 2014;46(1):3-14.
[6] Thorp JM, Jr. Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later. Scientifica. 2012;2012:Article ID 980812, 16 pages.
[7] Thorp, 2012; Pazole K, Zane SB, Parker WY, Hall LR, Berg C, Cook DA., Abortion Surveillance—United States, 2008. Morbidity and Mortality Weekly Report. 2011;60(1):1-41.
[8] A fact sheet distributed by the National Abortion Federation during the 1995 debates over partial-birth abortion asked “Why do women seek abortions later in pregnancy?” and answered “Women seeking later abortions do so for very serious reasons. All abortions taking place in the third trimester are for reasons of serious fetal abnormality or a risk to the life of the woman. Many abortions that occur from 18 weeks’ gestation through the end of the second trimester are for this reason as well.” In 2013, a referendum in Albuquerque, New Mexico was proposed to place a limit of 20 weeks on abortions performed in the city. In the ensuing debate, advertising produced by NARAL Pro-Choice America featured a woman who chose “termination” due to a “severe fetal anomaly,” a condition stated in the ad to be “primarily” the reason for late abortions.
[9] Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM., Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives. Perspectives Sexual Repro Hlth. 2005;37:110-118; Hammond, 2009
[10] Foster DG, Kimport K, Who Seeks Abortions at or After 20 Weeks? Perspectives Sexual Repro Hlth. 2013;45:210–218.
[11] Foster and Kimport, 2013.
[12] Foster and Kimport, 2013
[13] Foster and Kimport, 2013
[14] Foster and Kimport, 2013
[15] Foster and Kimport, 2013
[16] Foster and Kimport, 2013
[17] Foster and Kimport, 2013
[18] Thorp, 2012.
