The overwhelming majority of abortions—88 percent in 2006—are first-trimester procedures, occurring in or before the 13th week of pregnancy. While research has established that women who have abortions have different traits compared to all women of reproductive age—they are poorer, younger and less likely to be white—little is known about the characteristics of the subset of patients who have abortions after the first trimester. Given that second-trimester abortions cost more than first-trimester procedures and are offered by fewer providers, it is likely that this group of women differs from the majority who has the procedure earlier. To investigate these differences, the Guttmacher Institute recently undertook the first national study of women in the United States who have second-trimester abortions, the results of which will be published in a forthcoming issue of Contraception (and are already available online at http://www.guttmacher.org/pubs/journals/j.contraception.2011.10.012.pdf).
To conduct our analyses, we relied on data from Guttmacher’s 2008 Abortion Patient Survey, which gathered self-administered questionnaires from 9,493 abortion patients at 95 healthcare facilities across the United States. The study asked about age, race and how many weeks pregnant the woman was in addition to more sensitive topics such as exposure to domestic violence. The data are representative of all abortion patients in 2008.
What did we find? Of the 1.2 million abortions that occurred in 2008, 121,000, or 10 percent, were in the second trimester, defined as 13th to the 26th week of gestation. We found several groups of women to be overrepresented among those having abortions at 13 weeks or later, including African-American women, teens, women with a lower level of education, those using health insurance to pay for the procedure and those who had experienced multiple disruptive life events in the last year. For example, among black abortion patients, 13 percent terminated pregnancies at 13 weeks or later compared to 9 percent and 10 percent, respectively, for white and Latina women. Among abortion patients aged 19 and younger, 14 percent obtained abortions in the second trimester, a figure significantly higher than the proportion among women aged 20 and older (10 percent).
While our study did not examine reasons why these women were having an abortion, we expect several conditions may contribute to this age pattern. It may take younger women longer to recognize that they are pregnant; they may have a difficult time approaching a parent or trusted adult to discuss the pregnancy; or they may have more difficulties finding an abortion provider or coming up with the money to pay for the procedure (especially if they are trying to do so without involving an adult). Notably, while adolescents within the population of abortion patients were more likely to have a second-trimester procedure, these young women only accounted for 18 percent of all abortions and 24 percent of second-trimester procedures. Thus, the majority of abortions, including those in the second trimester, were for women aged 20 and older.
Adult women without a high school degree had the highest proportion of abortions at 13 weeks or later (13 percent), while women with college degrees had the lowest (6 percent). Again, we expect several dynamics may be at work. Less-educated patients may have less knowledge about reproduction and take longer to recognize they are pregnant. Similarly, they may have lower levels of health literacy and a harder time figuring out options, tracking down information about abortion or finding a provider.
Approximately one-third of abortion patients relied on either private health insurance or Medicaid to pay for the procedure, and these women were more likely than those who paid out of pocket to have an abortion at 13 weeks or later (14 percent vs. eight percent, respectively). Women who lack health insurance, or who have insurance that does not cover abortion, may be unable to afford a second-trimester procedure. Having and using insurance are two different things, however. Most women who have private health insurance do not use it to pay for abortion services, perhaps due to concerns about confidentiality and lack of knowledge about whether abortion services are covered. But because second-trimester abortions cost more than first-trimester procedures, women in these circumstances may be motivated to seek out information about coverage as well as decide that confidentiality is a secondary concern.
Women who experienced multiple disruptive events in the last year—such as being unemployed or falling behind on rent—were more likely to have an abortion in the second trimester. It is possible that these events lead to delays in recognizing the pregnancy as well as delays in accessing services. Alternately, some women who initially decide to carry a pregnancy to term may change their minds when confronted by an event such as losing a job or separating from a partner.
Because with each additional week of gestation abortions become more expensive and are offered by fewer providers, we wanted to see if there were differences among the population of women obtaining abortions at 16 weeks or later compared to those at 13–15 weeks. The only characteristic consistently and positively related to abortion at 16 weeks or later was using health insurance to pay for the procedure. In our more complex statistical analyses, once other factors were taken into account, we also found that women with the highest incomes actually had a relatively higher likelihood of having an abortion at 16+ weeks compared to poor women. Taken together, these two findings suggest that the higher cost and decreased availability of abortion services in later weeks make them less accessible to poor women and those paying out of pocket.
Prior research has found that the overwhelming majority of second-trimester patients would have preferred to have had their abortion earlier. Our findings suggest that certain groups of women—African-American women and those with less education—would most benefit from increased access to early abortion services. While expanded services could reduce the number of second-trimester abortions, the need for such procedures cannot be entirely eliminated. For one, diagnoses of fetal anomaly and maternal health complications often do not occur until the second trimester. Additionally, some women take longer to recognize they are pregnant and to decide that they are going to have an abortion, while the decisions of others are influenced by changes in their lives that occur after they find out they are pregnant.
For women needing second-trimester procedures, having health insurance or other financial resources to pay for abortion services is especially important. The average abortion patient pays $470 for a first-trimester procedure, but the cost can increase substantially with each additional week in the second trimester. Women who cannot afford to pay these increased costs out of pocket are then forced to carry an unwanted pregnancy to term. As of January 1, 2012, 16 states had laws that limit abortion coverage in health plans that will be offered in the upcoming health exchanges; eight of these states have limited abortion coverage more broadly in all private health plans they regulate. These restrictions, especially if adopted by more states, are likely to have a significant impact on women seeking second-trimester abortions. And yet, the irony here is that the growing number of restrictions on insurance coverage for abortion may paradoxically increase the need for second-trimester abortions by further delaying women’s access to services early in pregnancy.
Rachel K. Jones has been a senior research associate at the Guttmacher Institute since 1999. Her work there focuses on abortion and adolescent sexual health issues.
Lawrence B. Finer is the director of domestic research at Guttmacher. He studies the demography of unintended pregnancy and abortion in the United States.