A Public Health Perspective on Abortions Later in Pregnancy Within the US

Abstract: 

Abortions later in pregnancy, defined as abortions at or after 21 weeks, have been a controversial issue in public health and political debates despite making up about 1% of total abortions in the United States. From a public health perspective, these procedures are necessary for several medical reasons such as severe fetal anomalies or risks to the mother’s health. Opponents claim that abortions later in pregnancy are unethical, and that it is immoral to terminate a pregnancy at a point of advanced development. Other factors also contribute to abortions later in pregnancy such as the individual not finding out they were pregnant until later in their pregnancy, or systemic barriers such as cost, abortion restrictions, transportation barriers, or social support that has delayed their abortions into the 21st week. 

A reproductive justice framework should be implemented to empower women to make choices about their own bodies and hold the government accountable for making policies that will promote reproductive health. Flexible abortion policies, expansions in insurance coverage, access to resources to address barriers to abortions, and public education programs will create sustainable change in reframing the conversation around abortions later in pregnancy and maintain personal autonomy.

Introduction 

The topic of abortion and its implications has been polarizing the nation for several years. It has been a major focus within local and national elections and has become one of the main running points in Vice President Kamala Harris’ 2024 presidential campaign. Abortion has always been a deeply contentious issue, but few aspects of the debate are as polarizing as abortions later in pregnancy. Defined by the American College of Obstetricians and Gynecologists (ACOG) as abortions at or after 21 weeks, these procedures are the subject of numerous impassioned political, medical, and moral arguments. 

Abortions later in pregnancy are commonly referred to as “late-term abortions”, but the ACOG states that the phrase has no clinical or medical significance, since “term” refers to three weeks before and two weeks after a pregnancy’s due date. This means that a “late term” refers to about 41 weeks, at which abortions do not ever occur. The proper term to use instead is “abortion later in pregnancy”, and this will be used throughout the article. This is important because the language used when discussing reproductive health has a significant impact on its perception and can often be inherently biased and medically inaccurate (ACOG Guide to language and Abortion, 2023). Opponents of abortions later in pregnancy view it as a choice made by the pregnant person, and that it is inhumane and immoral, and should be banned. 

However, abortions later in pregnancy, represent about 1% of all abortions occurring in the United States (Gomez, 2024). These abortions occur due to medical complications such as fetal anomalies or maternal life endangerment, as well as barriers to care that cause delays in obtaining an abortion within the first trimester. The procedure is expensive and can often require travel for most patients. They normally require treatment over multiple days and are only performed by a subset of all abortion providers (Diamant, 2024).

Understanding the controversy behind abortions later in pregnancy means dissecting its medical, ethical, and political implications. Though these types of abortions account for a minute fraction of all abortions, they have become a focal point in national debates. A big reason for this is because much of the conversation around these types of abortions are surrounded by misinformation. Critics often construct a narrative to the media of abortions later in pregnancy being performed solely for non-medical reasons. Former President Donald Trump even went as far to say, “They will take the life of a child in the eighth month, the ninth month, and even after birth”. Trump also targeted former Virginia Governor Ralph Northam when he claimed, “He’s willing to, as we say, rip the baby out of the womb in the ninth month and kill the baby.”

This rhetoric is extremely harmful because it twists and manipulates reality and delegitimizes the necessity of these procedures that are critical in saving a mother’s life. It can have detrimental effects on the future of the country’s already crumbling abortion protection policies, and further jeopardize the future of women’s health and autonomy. 

Reasonings for Abortions Later in Pregnancy

Structural fetal anomalies are often only detected much later in pregnancy. Routine anatomy scans are performed around 20 weeks to monitor organ development. Many structural complications are discovered during these scans that would not have been previously detectable. A proportion of these fetal abnormalities are lethal, meaning that the fetus is almost certain to die before or shortly after birth. Examples of these lethal conditions are anencephaly (missing aspects of the brain and skull), hydranencephaly (underdeveloped central nervous system), bilateral renal agenesis (missing kidneys), or lethal dwarfing syndrome (severe skeletal disorder) (Sanders, 1990).  In these cases, many individuals would wish to terminate their pregnancies instead of taking the risk to carry the pregnancy until the fetus passes away, and to additionally avoid the mental and emotional trauma of delivering a baby that is almost guaranteed to die. 

Life threatening conditions that afflict the pregnant person can also develop later in pregnancy. These conditions can include early severe preeclampsia, severe intrauterine infections, or newly diagnosed cancer that requires immediate treatment (Gomez, 2024). 

Another common reason individuals get abortions later in pregnancy are because they do not find out they are pregnant until several months into their pregnancy. Almost half of individuals who received an abortion after 20 weeks did not suspect they were pregnant until later in pregnancy. A 2022 study recounts the story of a 21-year-old woman living in the southern United States who did not find out she was pregnant until her third trimester. She experienced no recognizable pregnancy symptoms, never became sick, and even experienced regular monthly periods. Known as a cryptic pregnancy, this affects 1 in 500 pregnant individuals (Kimport, 2022). Being unaware of a pregnancy can mean that the pregnant individual likely did not receive proper prenatal care or make healthy lifestyle adjustments, which can lead to severe fetal complications, and further increase the need for an abortion later in pregnancy. 

Other barriers to care including a lack of information on where to access abortions, transportation difficulties, lack of insurance coverage, or inability to pay for the procedure can also push an individual much later into their pregnancy, requiring an abortion much later (Gomez, 2024). 

Barriers to Access

From a public health perspective, restricting access to abortions later in pregnancy creates disastrous health outcomes. Individuals with life-threatening complications could be forced to risk their lives in carrying a pregnancy to term that puts them at a higher risk of hemorrhaging or contracting a serious infection (Diamant, 2024). Additionally, forcing someone to deliver a fetus that is incompatible with life will bring about severe mental and emotional trauma. This will also disproportionately burden marginalized groups that lack access to reproductive care and early prenatal care and face other barriers in abortion seeking services (Kimport, 2022).

Barriers to care are often the reason for someone needing an abortion later in pregnancy in the first place. These barriers could include a lack of prenatal care, proper screening services to identify complications earlier, being unable to access abortions in one’s home state, or not being able to afford an abortion (Gomez, 2024). 

A lot of these barriers, specifically being unable to access abortions in one’s home state and not being able to afford the costs associated with an abortion, have been further exacerbated after the overturning of Roe v. Wade in June 2022 during the Dobbs v. Jackson case. This eliminated the constitutional standard that had protected the right to an abortion in the United States, leaving any policies on abortion and abortion care to be now decided by the individual states (Gomez, 2024).

14 states have now banned abortion at any stage of pregnancy, and 11 others have bans at specific gestational limits. This means that millions of people will be rejected from receiving proper care in their home states, forcing them to seek out abortion services in other ones (Abortion in the United States dashboard, 2024). Out-of-state travel for abortion services has doubled in the first half of 2023 compared to the first half of 2020, likely due to the overturning of Roe v. Wade. It’s estimated that only 25% of people needing abortion care will be able to travel out of state to get one. Travel, transportation, and procedural costs will cause further obstacles for those traveling for an abortion, and disproportionately burden disadvantaged groups such as adolescents, immigrants, those living on lower-incomes, or those living with disabilities (Upadhyay, 2022). 

The Way Forward: Policy Recommendations 

One way to overcome these barriers is to expand insurance coverage for abortion services. There is no law that requires any health plan, employed-based included, to cover an elective abortion. Eleven states bar private plans from covering abortion in most circumstances. 26 states restrict abortion coverage within Affordable Care Act plans. 34 states bar federal funds from paying for abortion within Medicaid, except in cases of rape, incest, or to save the life of the mother. Due to all these limitations, it is not shocking to see that research published from one study in the Journal of Health Affairs found that 69% of patients paid out-of-pocket for their abortion (Appleby, 2022). 

While abortions later in pregnancy are insured in instances of saving the life of the mother, true equity starts with increasing insurance coverage for all abortions. Delays in accessing abortion services, especially in lacking insurance coverage, pushes people who want an abortion further along in their pregnancies, which leads to an increase in the total number of people needing abortions later in pregnancy (Gomez, 2024). 

The debate over the accessibility of abortions later in pregnancy should not be resolved through restrictive policies and bans, but rather with the collaboration of policymakers, healthcare providers, and public health organizations that will work to promote women’s, maternal, and fetal health. A reproductive justice framework should be incorporated into any decisions on abortion policy to protect women and their bodies. This framework focuses on bodily autonomy and “the human right to make personal decisions about one’s life, and the obligation of the government and society to ensure that the conditions are suitable for implementing one’s decisions” (Morrison, 2021). 

Policymakers should work to remove overly restrictive laws that criminalize abortion such as total bans with no exceptions for fatal fetal anomalies, or only allowing exceptions for rape and incest up to a certain number of weeks within pregnancy. States with these restrictive abortion laws have higher rates of delayed abortions due to the difficulty in accessing timely care.  (Abortion in the United States dashboard, 2024). If the goal is to reduce the number of abortions performed later in pregnancy, the focus should be on increasing comprehensive access to prenatal care, screenings, and early abortion services. And to take steps to break down financial barriers to reduce the need to perform risky and costly abortions later in pregnancy in the first place. 

Another crucial step is to invest in public health education surrounding abortion and reproductive health overall. Misinformation is at the heart of so much of the controversy surrounding abortions later in pregnancy and abortions overall. Getting out information about what abortions later in pregnancy entail and the true reasoning for why people receive them will be a big step in cutting down on objections due to misinformation. Also bringing awareness on where people can receive abortions, what specific insurance policies regarding abortions are, and resources to address additional barriers such as transportation can all work to create a more informed public discussion on abortion that is not focused on attacking people and shaming them for their choices. 

Conclusion

Two fundamental values that are often lacking in the discussions surrounding abortions later in pregnancy are nuance and empathy. As mentioned before, abortion is an extremely nuanced issue because it involves an intersection of medical, ethical, political, and social considerations. There are several things to consider when it comes to framing policies on abortion such as bodily autonomy, fetal protection, maternal health, cultural beliefs, and political impact. The ethical arguments made by opponents of abortions later in pregnancy often oversimplify the concept and portray it as a decision people make casually when they decide 6 months into their pregnancy that they don’t want to have a baby anymore. The reality is that people who experience abortions later in pregnancy experience both physical and emotional trauma when making this extremely difficult decision. It’s important to have empathy for those in this situation, no matter what context they find themselves receiving an abortion in.

It is also important to address valid concerns to ensure access to safe, necessary abortions later in pregnancy while also including provisions to prevent misuse, but our goal in policy should not be to ban or restrict abortion. Historically, restrictions have never yielded sustainable results (prohibition of alcohol, war on drugs, abstinence-only education). Instead, we need to shift our focus on trusting, supporting, and empowering the women of this country in making informed decisions about their own health and their own bodies, and work to find the harmony between the health implications, ethical considerations, and personal autonomy of abortions and abortions later in pregnancy. 

References

Abortion in the United States dashboard. KFF. (2024, August 14). https://www.kff.org/womens-health-policy/dashboard/abortion-in-the-u-s-dashboard/

ACOG Guide to language and Abortion. ACOG. (2023). https://www.acog.org/contact/media-center/abortion-language-guide

Appleby, J. (2022, July 13). Three things to know about health insurance coverage for abortion. NPR. https://www.npr.org/sections/health-shots/2022/07/13/1111078951/health-insurance-abortion

Diamant, J. (2024, March 25). What the data says about abortion in the U.S. Pew Research Center. https://www.pewresearch.org/short-reads/2024/03/25/what-the-data-says-about-abortion-in-the-us/

Ivette Gomez, A. S. (2024, July 23). Abortions later in pregnancy in a Post-Dobbs era. KFF. https://www.kff.org/womens-health-policy/issue-brief/abortions-later-in-pregnancy-in-a-post-dobbs-era/

Kimport, K. (2022, June). Is third-trimester abortion exceptional? Two pathways to abortion after 24 weeks of pregnancy in the United States. Perspectives on sexual and reproductive health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9321603/

Morrison, T. (2021, May 12). Reproductive Justice: A radical framework for researching sexual and reproductive issues in psychology. Wiley Online Library.

https://compass.onlinelibrary.wiley.com/doi/abs/10.1111/spc3.12630

Sanders, R. (1990, January 28). Prenatal ultrasonic detection of anomalies with a lethal or disastrous outcome. Radiologic clinics of North America. https://pubmed.ncbi.nlm.nih.gov/2404299/

Upadhyay, U. D. (2022, September). Barriers push people into seeking abortion care later in pregnancy. American Journal of Public Health. https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/35969829/