Who Has Late Abortions -- And Why?

The last-minute decision by Congressional Republicans not to vote on a 20-week abortion ban on the anniversary of Roe v. Wade stemmed from disagreement about rape victims. Missing from the discussion were other women who have abortions later than 20 weeks of pregnancy. They deserve attention. Late abortion concerns women in difficult circumstances.

How common are late abortions?

According to the Centers for Disease Control and Prevention, only one percent of abortions in the U.S. are performed after 20 weeks of pregnancy. This has been true for years. Nearly two-thirds of all abortions (63 percent) take place at 8 weeks or earlier, when the embryo is so small that it cannot be seen with the naked eye. Despite its rarity, late abortion attracts disproportionate attention.

Why so late?
Many factors contribute to delays for women having abortions. Women requesting abortions in the second trimester often face social challenges. They are more likely to be teenagers, poor, African-American, and with lower educational attainment than women who have first-trimester abortions. An early study found that a history of irregular menstrual periods was related to delayed recognition of pregnancy. Lower educational attainment and lack of early pregnancy symptoms were also associated with delayed recognition of pregnancy.

More recent studies have confirmed that minors and poor women have delays accessing care. Obesity, abuse of drugs or alcohol, a prior second-trimester abortion, and being unsure about last menstrual period have also been found related to delay.

Financial problems
Lack of money poses a huge challenge for many women seeking an abortion. Since most women pay for abortions out-of-pocket, scraping together the requisite funds can be difficult if not impossible for many.

Logistical challenges
Many women live long distances from an abortion provider, and second-trimester services are even more scarce. Finding a provider and getting there are common challenges. Travel costs and overnight stays (often required by state-mandated waiting periods) pose serious obstacles for many. Women living on minimum wage and without a car must often get transportation from family or friends. Most women having abortions already have children, and arranging for child care during an overnight stay adds to the logistical burden.

Late prenatal diagnosis
Fetal abnormalities often are not discovered until well into the second trimester of pregnancy. These include genetic abnormalities (such as trisomy 21, trisomy 18, and trisomy 13) and central nervous system defects. If the nervous system tube does not close during development of the embryo, anencephaly (no brain) or meningomyelocele (spina bifida) results. Most women who learn of these fetal diagnoses choose abortion.

Representative patients

Here are some circumstances leading to abortions after 20 weeks:
  • A woman whose fetus was found to have a lethal congenital heart defect.
  • A 26-year-old intellectually handicapped woman impregnated by an unknown man in her group home.
  • A mother of three who had to sell the family car to pay for her abortion.
  • A 13-year-old found to be pregnant only when her eighth-grade teacher noticed her swollen belly.
  • A woman with newly diagnosed cancer whose chemotherapy could not be started while she was pregnant.
  • A mother of four with recurrent heart disease hospitalized 9 weeks for heart failure after her last delivery.
  • A 14-year-old impregnated by her mother's boyfriend.
  • A 36-year-old with chronic schizophrenia whose three children have been placed in foster care.
  • Women in difficult circumstances
    Late abortions comprise a tiny fraction of all abortions. However, these women are often in the greatest medical need. They suffer from poverty, domestic violence, medical and psychiatric illness, abandonment, rape, and other forms of reproductive coercion.

    Ironically, the epidemic of abortion restrictions in recent years has increased the likelihood that women will request late abortions, rather than early ones. Delays, whether they are financial, logistical, or legal, hurt women's health and are thus unethical. As warned by the American College of Obstetricians and Gynecologists, imposition of an arbitrary 20-week abortion ban is "inappropriate, ill advised, and dangerous."

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