Why do women need later abortion care?
Who seeks later abortion care?
In 2014, the US Centers for Disease Control and Prevention (CDC) reported that only 1.3% of all abortions occurred at or after 21 weeks gestation. The CDC also reported that approximately 91.5% of abortions occurred in the first 14 weeks of gestation, 3.3% occurred between 14-15 weeks’ gestation, and 3.9% occurred between 16 and 20 weeks’ gestation [1]. In order to get a better understanding of what may lead some women to seek an abortion during the second trimester, several research groups have surveyed women who have both obtained and been denied later abortions and compared their demographic characteristics with women who have obtained first trimester abortions. In 2017, the Guttmacher Institute found that being Black, having less than a high school degree, relaying on financial assistance to pay for a procedure, living at least 25 miles away from an abortion clinic, and experiencing delay in finding out they are pregnant were all associated with abortion in the second trimester. [2]. A 2013 US study by researchers at the University of California San Francisco’s Advancing New Standards in Reproductive Health (ANSIRH) conducted the Turnaway study, a five-year prospective study that compared individuals who had an abortion at 20 weeks’ gestation or later with those seeking a first trimester abortion. They found no significant differences in race or ethnicity, and that those who obtain later abortions are more likely to be younger and to be unemployed [3].
What factors can cause delay?
Several factors have been identified as contributing to delay in seeking abortion until the second trimester or later. Reasons why an individual may need an abortion after the first trimester include delays in finding out they are pregnant [2-9], needing time to decide what to do about an unintended pregnancy [3-4], difficulties accessing care due to locating and traveling to a provider [2-3] [14-15], and needing time to raise funds to pay for the procedure or for travel arrangements [10-13].
Delays in finding out about pregnancy and needing time to make decisions
The Turnaway study, mentioned above, found that those who had a first trimester abortion found out that they were pregnant at an average of five weeks after their last menstrual period, while those who had abortions at 20 weeks or later found out that they were pregnant at an average of 12 weeks after their last menstrual period. Both sets of individuals reported delays in finding out that they were pregnant (40% vs. 45%, respectively) [3]. Studies conducted by Ibis Reproductive Health and the Guttmacher Institute, both found that delays in finding out pregnancy to be related to second-trimester abortion [4] [2]. A 2008 study found several risk factors for delayed pregnancy testing, including obesity, substance abuse, previous second trimester abortion, and uncertainty about the date of a woman’s last menstrual period [5]. Women with a history of spotting in-between periods and irregular periods are also more likely to obtain a later abortion, as it may be harder for them to determine when they become pregnant [6] [7]. It can be difficult for women to estimate how far their pregnancy has progressed and this may also contribute to a delay[8]. In a study of 232 women seeking second trimester abortion, 46.6% had underestimated how far their pregnancy had progressed by at least 4 weeks [8]. Women who seek later abortion due to a fetal anomaly may have been unable to discover these anomalies any earlier in their pregnancy because the tests that identify them are not done until the second trimester [9].
Studies have also found that delays may arise from needing time to make a decision about ending a pregnancy. The Turnaway Study found that those seeking a first trimester abortion and those seeking an abortion after 20 weeks both reported delays due to trouble deciding to end the pregnancy (33% vs. 40%), and disagreements with partners (16% vs. 20%) [3]. These findings are consistent with the Ibis study [4].
Cost and logistics
Financial and logistically barriers, such as difficulty locating a provider, lack of insurance coverage or adequate funds for the abortion and related travel costs, become even more significant for women who need a later abortion [10]. It is estimated that women may have to spend as much as two-thirds of their monthly income for a second trimester abortion [10] [11]. Analysis from the Turnaway study found that individuals receiving first-trimester abortions to those obtaining abortions at or after 20 weeks found that the median cost of a procedure rises from approximately $460 in the first trimester to $750 between 14 and 20 weeks and $1,750 after 20 weeks [11]. Although many abortion patients have private insurance coverage, most do not have their abortions covered due to lack of knowledge of whether an abortion is covered, or concerns about confidentiality. For those with Medicaid insurance, state restrictions on abortion coverage may block the use Medicaid funds to cover the procedure [12] [13].
Logistical barriers including finding and traveling to an abortion provider are especially difficult for those seeking later abortion care. The Turnaway study found that 21 percent of individuals seeking abortions at or after 20 weeks of gestation traveled more than three hours to get to the abortion facility, compared to only five percent of those having abortions at or before 13 weeks of gestation [3], which further contributes to increased costs due to travel expenses, child care, and lost wages. Similarly, the Guttmacher Institute study found that being at least 25 miles away from the abortion facility was associated with obtaining abortions at or before 13 weeks of gestation [2]. These challenges are further exacerbated by the decreasing number of abortion clinics throughout the country [14], and the growing number of statewide bans on second trimester abortion procedures (D&E bans) [15].
For more information about why women need later abortion care see the Related Research in our archives.
View our fact sheet Who needs abortion later in pregnancy in our Tools for Advocates section.
References
1. Jones RK and Jerman J, Abortion incidence and service availability in the United States, 2011. Perspectives on Sexual and Reproductive Health. 2014, 46(1):3–14, doi:10.1363/46e0414.
2. Jones RK, Jerman J. Characteristics and circumstances of U.S. women who obtain very early and second-trimester abortions. PLoS One. 2017;12(1):e0169969
3. Foster DG,Kimport K. Who seeks abortions at or after 20 weeks? Perspectives on sexual and reproductive health. 2013; 45(4): 210-218
4. Blanchard K, Meadows JL, Gutierrez HR, Hannum CPS, Douglas-Durham EF, Dennis AJ. Mixed-methods investigation of women’s experiences with second-trimester abortion care in the Midwest and Northeast United States. Contraception. 2017;96(6):401–10.
5. Foster DG, Jackson RA, Cosby K, Weitz TA, Darney PD, Drey EA. Predictors of delay in each step leading to an abortion.Contraception. 2008; 77(4): 289-293
6. Swanson M, Karasek D, Drey E, Foster DG. Delayed pregnancy testing and second-trimester abortion: can public health interventions assist with earlier detection of unintended pregnancy? Contraception. 2014; 89(5): 400-406
7. Ingham R, Lee E, Clements SJ, Stone N. Reasons for second trimester abortions in England and Wales. Reproductive health matters. 2008; 16(31): 18-29
8. Janiak E, Kawachi I, Goldberg A, Gottlieb B. Abortion barriers and perceptions of gestational age among women seeking abortion care in the latter half of the second trimester. Contraception. 2014; 89(4): 322-327
9. Kerns, JL, Swanson M, Pena S, Wu D, Shaffer BL,Tran SH, Steinauer JE. Characteristics of women who undergo second-trimester abortion in the setting of a fetal anomaly. Contraception. 2012; 85(1): 63-68
10. Kiley JW, Yee LM, Niemi CM, Feinglass JM, Simon MA. Delays in request for pregnancy termination: comparison of patients in the first and second trimesters. Contraception. 2010; 81(5): 446-451
11. Roberts SC, Gould H, Kimport K, Weitz TA, Foster DG. Out-of-pocket costs and insurance coverage for abortion in the United States.Women's Health Issues. 2014; 24(2): e211-e218
12. Guttmacher Institute. State laws and policies: Restricting insurance coverage of abortion.. 2014. Available from: https://www.guttmacher.org/state-policy/ explore/restricting-insurance-coverage-abortion. Accessed April 9, 2019.
13. Guttmacher Institute. State laws and policies: State funding of abortion under Medicaid. 2018. Available from: https://www.guttmacher.org/state-policy/ explore/state-funding-abortion-under-medicaid. Accessed April 9, 2019.
14. Jatlaoui TC, Shah J, Mandel MG, et al. Abortion Surveillance — United States, 2014. Morbidity and Mortality Weekly Report Surveillance Summaries. 2017; 66(-24):1–48. DOI: http://dx.doi.org/10.15585/mmwr.ss6624a1.
15. Guttmacher Institute. State policies on later abortions. August 1, 2018. Available from: https://www.guttmacher.org/state-policy/explore/state-policies-laterabor.... Accessed April 9, 2019.
