Why do clinicians provide later abortion care?

In the words of Dr. Wendy Chavkin, “We shouldn’t have to ask doctors to be heroes—to withstand harassment, isolation, violence, invasions of their patients’ confidentiality, and scientifically unfounded interference with the content of their work—but in today’s America we do.” Later abortion providers have various motivations for continuing to perform abortions, with the most commonly reported reasons being the need for later abortions to preserve the life and health (physical and/or mental health) of the woman, the understanding that motherhood would pose a crippling burden on especially vulnerable, economically disadvantaged women, and simply compassion and kindness [1]. Dr. George Tiller, who provided later abortions in Kansas for many years until his untimely murder, stated that “abortion is about women’s hopes, dreams, potential, the rest of their lives. Abortion is a matter of survival for women” [2]. However, their practice is often met with opposition by various institutional and social obstacles:

Stigmatization. Abortion providers often experience various degrees of stigmatization by both the general public and by their own health colleagues. As shown in the 2013 film After Tiller, later abortion providers are often the target of harassment and even violence [3]. To date, very few providers are willing to disclose if/that they offer later term abortion, which implicates access for those in need of services [4].

In addition to broader social stigma, many providers indicate that institutional or coworker barriers are significant barriers to later abortion provision. Among these barriers, lack of support from nursing colleagues was the reason most often cited [5, 6]. Workshops aimed at clarifying values may also help to create a more supportive environment and strengthen coping mechanisms [7].

Stigmatization may be unintentionally exacerbated by provider behavior. That is, providers may censor themselves in their discussions about later abortion, fearing that honest acknowledgement of difficult aspects may be dangerous to the pro-choice movement, and in doing so inadvertently legitimize the anti-abortion stance that second trimester abortion is unethical. It is necessary that pro-choice discourse be honest about the nature of abortion procedures and uses this honesty to strengthen abortion care, including second trimester abortion [8].

Lack of training. In the US, training in D&E is not required by the American Board of Obstetrics and Gynecology, but 80% of Maternal-Fetal Medicine fellows believe that D&E training should be offered during fellowship.  A training gap therefore exists, as a substantial number of fellows desire D&E training [9]. Lack of training has been cited as a barrier in other countries as well. In a survey of abortion providers in Scotland, where the majority of providers support provision beyond 16 weeks, lack of training was a perceived barrier by over half of providers surveyed. Lack of service accommodations and support among senior management were also reported to be major barriers [10]. In Italy, midwives believed that university education was not enough, and that continuous training is necessary to provide effective and compassionate care [11].

Burnout and lack of staff support. Performing later term abortion requires both professional knowledge and empathy. Providers often state that the feeling of “doing something good for women’s rights bridges the difficulty” that providers face in caring for women undergoing later abortion [12]. Mentorship from experienced and knowledgeable colleagues and structured opportunities for reflection and support may enable providers to develop resilience, stability, and confidence [12]. Additionally, cooperation among colleagues—i.e., dividing the workload and sharing knowledge and competencies—is cited as an effective means of achieving needed professional support [11].

Restrictions. Even if providers believe that an abortion is an acceptable indication for a pregnancy at a later gestational age, they may be limited by their local jurisdiction. Providers are often forced to turn away women around 20 weeks for fear of criminalization. For more information on restrictions, please see State Data.

Dr. Susan Robinson, one of the few doctors to openly provide third-trimester abortions, has found that many people fail to recognize that “late abortion decisions are carefully made by these women. They have been thought out, wrestled with, agonized over. They are never casual. And no matter how available birth control and first-trimester and second-trimester abortion is, you are always going to have the need for later abortions” [4]. Awareness of this reality is needed to support the provision, and experience thereof, of later abortions.

For more information about provider experience see the Related Research in our archives.

  1. Physicians for Reproductive Health. Why i provide abortions. 2015
  2. Physicians for Reproductive Health. Dr. George Tiller: Remembering a hero. 2013;2015
  3. After Tiller. After Tiller. 2013;2015
  4. Tolentino J. Interview with Dr. Susan Robinson, one of the last four doctors in america to openly provide third-trimester abortions. 2013;2015
  5. Turk JK, Steinauer JE, Landy U, Kerns JL. Barriers to d&e practice among family planning subspecialists. Contraception. 2013;88:561-567
  6. Kade K, Kumar D, Polis C, Schaffer K. Effect of nurses' attitudes on hospital-based abortion procedures in massachusetts. Contraception. 2004;69:59-62
  7. Turner KL, Hyman AG, Gabriel MC. Clarifying values and transforming attitudes to improve access to second trimester abortion. Reprod Health Matters. 2008;16:108-116
  8. Harris LH. Second trimester abortion provision: Breaking the silence and changing the discourse. Reprod Health Matters. 2008;16:74-81
  9. Rosenstein MG, Turk JK, Caughey AB, Steinauer JE, Kerns JL. Dilation and evacuation training in maternal-fetal medicine fellowships. Am J Obstet Gynecol. 2014;210:569 e561-565
  10. Cochrane RA, Cameron ST. Attitudes of scottish abortion care providers towards provision of abortion after 16 weeks' gestation within Scotland. Eur J Contracept Reprod Health Care. 2013;18:215-220
  11. Mauri PA, Ceriotti E, Soldi M, Guerrini Contini NN. Italian midwives' experiences of late termination of pregnancy. A phenomenological-hermeneutic study. Nurs Health Sci. 2015;17:243-249
  12. Andersson IM, Gemzell-Danielsson K, Christensson K. Caring for women undergoing second-trimester medical termination of pregnancy. Contraception. 2014;89:460-465



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