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It’s her body.
IT'S HER CHOICE

The truth about how women get abortions in America

By Annalisa Merelli

This item has been corrected

Once again, abortion is front and center in the US, following the Sept. 29 congressional hearing on defunding Planned Parenthood, which provides gynecologic services including screenings for cervical cancer (pap test), contraception and abortions.

Abortion is also a campaign issue—and a lot of the facts related to it have been misused and misquoted by candidates to gain popular support. In the hope of setting the record straight, Quartz spoke with Pratima Gupta, a gynecologist from Physicians for Reproductive Health and Gretchen Borchelt, vice president for health and reproductive rights at the National Women’s Law Center.

What does US law say about abortions?

In 1973, the Supreme Court’s decision on the landmark case Roe v. Wade, stated that American women have the constitutional right to seek abortions. This makes abortion legal in all US states. However, the court stated the right to abortion was not absolute, and ruled that states can restrict or altogether ban (pdf) abortions after what is called “fetal viability,” the ability of a fetus to survive outside the maternal womb, in absence of placenta.

In numerous countries there is a time limit on the legality of abortion—for the UK, it’s 24 weeks, for France 12 weeks, for Italy 90 days. In the US, determining the ”fetal viability” is left to the medical practitioner’s discretion. Generally speaking, viability occurs between 24 and 28 weeks (seven months), but every pregnancy is different, which places the very concept of viability at the center of a heated debate.

Why is legal abortion necessary?

Safety. Within three years of abortions being legal, abortion-related deaths fell from 40 per million live births to eight. In 2011, 10 deaths were connected with surgical or medical abortions out of 730,322 procedures. The US is the Western country with the highest relative number of abortions (20.8 per thousand women), and has the 13th highest relative number of abortions in the word.

Can states ban abortions?

No. At least, not unless the 1973 verdict is overturned. However, several states have passed bills that would come into effect if the Supreme Court decision on the right to abortion were to be overturned. Currently, states have the power to prohibit and limit abortions after a fetus is viable (with exceptions for the health of the mother). In some states, abortion is limited to health issues (pdf) after one trimester or 20 or 24 weeks—however, such limitations often are conflicting with the Supreme Court requirements (pdf) and can be challenged. States can also mandate counseling for women requesting abortions, and some of them do.

While states can’t make abortion altogether illegal, in some of them it’s is de-facto absent. One outstanding case is Mississippi, where the whole state is served by only one abortion clinic.

How are abortions performed?

There are two types of abortions: medical abortion, done through medications, and surgical abortion. For women within the first trimester both are viable options and the choice is up to the woman.

Medical abortion

Medical abortion received FDA approval in 2000, and is chosen by a growing number of women (19.1%). It is done through two pills. The first, called mifepristone, stops the embryo’s growth. The second, misoprostol, is taken two days later and contracts the uterus to expel the embryo. A medical abortion can be performed by a doctor and by a nurse practitioner or midwife in many states, and it can occur until the 9th week, when the embryo is about 0.75 inches long (19 mm).

Surgical abortion

Surgical abortion is performed in two different ways. If a woman is within the first trimester (when the fetus is about 2.5 inches long, or six cm) abortion is done through suction—both the fetus and the placenta are aspirated out of the woman’s uterus. This is generally a simple procedure, lasting up to 15 minutes, and it can be performed by one person, either a doctor or—in some states—a nurse practitioner.

Around the 12th week (depending on the woman), the procedure becomes significantly different, because it requires a two or three days preparation for the cervix to dilate prior to the actual surgery. The number of gynecologists who don’t have the required training for it is relatively large, which, added to many doctors’ unwillingness to offer the procedure anyway, can make access to abortion difficult.

This becomes even harder after the 24th week, or when, in most states, a woman is only allowed to have an abortion for life-threatening conditions and serious health issues. There are reportedly only four doctors in the US that offer third-trimester abortions.

How much does an abortion cost?

It depends on many factors. A number of insurance policies cover elective abortions, though not all. Medicare, for instance, only covers abortions resulting from incest or rape, or if the pregnancy is life-threatening to a woman. The same is true of military insurance and Medicaid, though certain states provide coverage of abortions through Medicaid. The median cost of surgical abortion at 10 weeks is $470.The cost of a surgical abortion within the first trimester is up to $1,500, and varies depending on the provider. Abortions after the third month are generally more expensive.

Medical abortion is cheaper than the surgical procedure. Its median cost is $490 and can go up to $800.

Are federal funds used to finance abortions, or subsidize them for low-income women?

No, federal funds cannot be directed toward abortion procedures. Even when funding is given to organizations (such as Planned Parenthood) that offer abortions, it cannot be used for abortions.

How about state funds?

Seventeen states cover abortion costs as part of female reproductive health funding. Four of them (Hawaii, New York, Maryland, Washington) did so voluntarily, while 14 (Arkansas, Arizona, California, Connecticut, Illinois, Massachusetts, Montana, Minnesota, New Jersey, New Mexico, Washington, West Virginia, and Vermont) have after being ordered by state courts.

When do women seek abortions in the US?

The majority of abortions occur before the first trimester, with less than 10% happening after the 12th week.

Why do women seek abortions after the first trimester?

There are many reasons a woman might seek an abortion between the 13th and 20th gestational week. Her health (physical or mental), finances, or life situation might have changed. In some cases, women might have decided to have an abortion early on, but were unable to get access to one because of costs, lack of clinics in the area, and difficulty getting time off work.

Further, some of the pregnancy tests that can determine serious birth defects, including amniocentesis, are performed after the 14th week, and it’s often when women get negative results from these tests that they decide to get later abortions. For instance, half of the pregnancies where the fetus is found to have Down syndrome are terminated.

Would making abortion illegal stop abortions?

Likely not. Women of all cultures have been having abortions for thousands of years (pdf, p.1), whether or not the law allowed them to do so. The overwhelming majority of women who have had abortions do not regret it.

Correction: In a medical abortion, mifepristone is used to stop the embryo’s growth.