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, among other means, bans on postviability procedures, laws imposing a fixed date for fetal viability, and so-called "partial birth" abortion bans, many of 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 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., 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 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, 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 rises 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. Discovery of serious fetal anomalies, such as severe genetic disorders, or conditions in which the woman's health is threatened or aggravated by continuing her pregnancy include

• malignant hypertension, including preeclampsia
  
  
• out-of-control diabetes
  
  
• heart failure
  
  
• severe depression
  
  
• suicidal tendencies
  
  
• serious renal disease
  
  
• certain types of infections

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

Other Reasons for Postponing Abortion Past 12 Weeks

• lack of financial and/or emotional support from the male partner
  
  
• 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 (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 often cause delays.

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 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).

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. 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.
  
  
• 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.

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 must be permitted to use the method most likely to preserve the woman's health, even if it might endanger fetal survival.
  
  
• 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.
  
  
• 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. The majority of these states passed laws similar to Nebraska's, and most have been held invalid or are unenforceable (CRLP, 2001).