Opponents of abortion have long tried to stigmatize the medical procedure, but in the past few years, they've targeted abortions performed in the second and third trimester. President Donald Trump and Vice President Mike Pence have repeatedly claimed that Democratic lawmakers support "late-term abortions" done "up to the moment of birth."
Doctors, meanwhile, have repeatedly explained that they do not perform abortions while people are in labor, or in the days before their due date, but the talking point persists. "My patients didn't ask to be spoken about this way, they didn't ask for their health care to be politicized, and they're the ones that are suffering the most from all of this," Jen Villavicencio, MD, MPP, an ob-gyn and abortion provider in Michigan and the Darney-Landy Fellow at the American College of the American College of Obstetricians and Gynecologists, tells Health.
"Inflammatory language like 'late-term abortion' is used to deflect the conversation away from the safe, legal provision of compassionate medical care to patients," Dr. Villavicencio says. Here, ob-gyns and abortion providers cut through the political talking points and focus on the facts regarding abortions later in pregnancy. This is what you need to know.
What do politicians mean when they say ‘late-term abortion’?
In short, it's a sensationalized phrase that doesn't reflect science or medicine. While people may have heard physicians use "late term" in a medical setting, it refers to women in the 41st week of their pregnancy, that is, women who are still pregnant after their due date, and no abortions occur during this time period, Dr. Villavicencio says. Physicians instead say "abortions later in pregnancy" or "later abortions," or simply refer to the trimester when the procedure happens.
What is a later abortion, and how often does it happen?
It depends on who you ask, but generally later abortions are those that happen after a specific point in pregnancy (for example, beyond 20 weeks or in the third trimester) or after a fetus is viable, which is thought to be at about 24 weeks though that's not a hard and fast rule. There is no magic switch that flips in the same week of every pregnancy after which that fetus is viable; viability is determined by a physician on an individual basis.
Abortions in the second trimester are most often done via a procedure known as dilation and evacuation, or D&E, where the cervix is dilated either with medication or seaweed sticks known as laminaria that swell and open the cervix, and then the pregnancy is removed through the cervix using instruments. Abortions in the third trimester, which are a very small number of procedures, involve inducing labor, Daniel Grossman, MD, and ob-gyn and abortion provider and a professor of obstetrics at the University of California San Francisco and director of Advancing New Standards in Reproductive Health (ANSIRH), tells Health.
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These later abortions are rare: According to the Centers for Disease Control and Prevention, in 2016, just 1.2% of abortions were performed at 21 weeks of pregnancy or later. Another 7.7% were done from 14 to 20 weeks, while the vast majority, 91%, were performed at or before 13 weeks. Put another way, this means 98.7% of all abortions happen before 21 weeks. Dr. Grossman says there isn't great data on the breakdown of procedures after 21 weeks but, he says, "it's clearly much less than 1% past 24 weeks."
Given that these later procedures are so uncommon, Dr. Villavicencio says: "The political focus on abortion later in pregnancy does not reflect the medical reality and disproportionately impacts those who find themselves in need of critical healthcare."
Why do people get later abortions?
There are several reasons why people have later abortions, and they generally fall into two categories. "It's either due to some new information that has come about during their pregnancy or a result of barriers that exist to getting abortion," Dr. Villavicencio says.
The "new information" category includes learning something about the health of the fetus or the pregnant person, but it also encompasses people not realizing they're pregnant until later on. This can happen because they're using birth control, they have irregular periods, or they're young and not aware of pregnancy symptoms, Dr. Grossman says. Dr. Villavicencio says she's had abortion patients who are grandmothers and didn't think they could get pregnant. Late recognition of pregnancy is "not unusual, and certainly not a fault of someone for not knowing. Unless you're taking a pregnancy test every single month, which no one does, it's very easy to miss a pregnancy," she says.
Fetal health problems could include a malformation of the fetus or genetic abnormality that means the fetus won't survive. But these problems often aren't diagnosed until later in the second trimester or into the third because the screening tests and scans don't pick these problems up until that late, Dr. Grossman says. The special ultrasound that's colloquially known as "an anatomy scan"—where the fetus is large enough that doctors can see the heart, brain and spine—isn't usually done until 18 or 20 weeks, but can be as late as 23 weeks, based on the availability, where a person lives, or even what's going on in their life, Dr. Villavicencio says. Then if the scan does pick up something concerning, people need time to get a specialist appointment for a second opinion.
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Similarly, people can develop dangerous health complications in pregnancy that may not emerge until the later second trimester or early third trimester. Two examples are pre-eclampsia, or high blood pressure later in pregnancy that can become life-threatening, and placenta previa, when the placenta is covering the opening of the uterus and can cause severe bleeding during pregnancy. The treatment for these conditions is delivery and C-section, respectively, Dr. Grossman says, but if the patient is still in their second trimester and the fetus isn't viable, abortion is sometimes the best option for their health.
Barriers to accessing care can also push people who want abortions to get them later in pregnancy. These obstacles include living far away from an abortion clinic thanks to anti-abortion clinic shutdown laws, facing a medically unnecessary state-mandated waiting period of 24 to 72 hours that requires multiple trips to a clinic, and the costs associated with that travel such as gas, hotel stays, childcare (60% of people seeing abortions already have kids), and unpaid time off from work. Plus if you're having an abortion procedure rather than getting the abortion pill to take at home, you might need someone to travel with you, Dr. Villavicencio says.
Another is the cost of the procedure itself—an average of just over $500 at 10 weeks in 2014—which may not be covered by health insurance, especially for people living on low incomes who have Medicaid. Thanks to the 1976 Hyde Amendment, the federally funded Medicaid program can only cover abortions in the cases of rape, incest, or threat to the mother's life. States can use their own funding to cover the procedure, but only 16 do so while 34 states and Washington, DC, stick to the federal standard, according to the Kaiser Family Foundation. Because of structural racism, Black and Latinx women are more likely to have Medicaid insurance and are thereby less likely to have the procedure covered.
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The price of the procedure is, of course, added to any travel costs mentioned above. "That is a real, real barrier for many patients," Dr. Grossman says. "[The Hyde Amendment is] a common reason why people end up presenting for care in the second trimester because it took time for them to get the funding together to be able to pay for the abortion." And the later an abortion is, the more expensive it is, so the problem snowballs.
By contrast, in a 2012 study in the American Journal of Public Health, Dr. Grossman found that in the two years after Iowa made early medication abortions easier to access through a telemedicine program, that people were almost 50% more likely to have a first-trimester abortion while second-trimester abortions declined, even after controlling for other factors.
"I think there's a lot of evidence showing that these restrictions can push people later in pregnancy and increase the likelihood that they'll get a second-trimester abortion, and conversely, that efforts to expand access to early abortion can help to reduce second-trimester abortion," Dr. Grossman says.
Which states restrict later abortions?
Forty-three states ban abortion after a specific gestational age, with 17 banning it after 20 weeks, while seven states do not have gestational limits, according to the Guttmacher Institute.
Under the Supreme Court rulings Roe v Wade and Planned Parenthood v Casey, states can only ban abortion after the fetus has reached viability, meaning it could survive outside the womb, as long as there are exceptions to save the life and health of the mother. That framework means state bans after viability don't have to permit exceptions for people who faced barriers to getting care or those whose fetuses have severe anomalies.
Of the 17 states with 20-week bans in effect, 13 lack exceptions for lethal fetal anomalies, meaning people who want abortions in those cases would have to travel out of state. States that have passed bans before viability have typically done so in an effort to provoke a Supreme Court challenge, per Guttmacher. Gestational age bans also ignore the medical reality that some pregnancies will never be viable.
What do politicians mean when they talk about babies “born alive” in abortions?
President Trump has also repeatedly claimed that doctors are delivering healthy babies and then "executing" them, which does not happen.
There are rare cases where the fetus has been diagnosed with a severe condition that is clearly incompatible with life. After counseling with their medical team and specialists, some patients choose to induce labor, knowing that the fetus will not survive after delivery, and offer comfort care. This is called perinatal palliative care and it's an accepted medical practice, Dr. Grossman says. Sometimes people choose to induce labor rather than having a D&E procedure because they want to hold their baby or because the labor process will be cathartic for those who were preparing to deliver, Dr. Villavicencio says.
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Dr. Villavicencio says these are "heart-wrenching, tragic" situations where the decisions made are no different than other end-of-life care—it's just that this is at the other end of the spectrum of life. Families are deciding whether they want to take futile steps like intubation and CPR or let their loved one pass away peacefully. But crucially, "it is not medical dying and it's not physician-assisted suicide and it is not hastening the death of anyone in any way," she says. "This is purely a way to offer as much comfort as possible while the inevitable occurs."
These are not abortions of healthy pregnancies. "This is not 'hey by the way, I forgot I want an abortion.' They've had conferences with the neonatal intensivists, with the obstetricians, with the pediatricians, with the palliative care team to discuss how and when this palliative birth is going to occur," Dr. Villavicencio says. "If [politicians] were being honest about what they were talking about, they wouldn't be talking about 'moment of birth,' because that's not when the abortion decision is being made."
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