It was hard—and it was something I just knew right away," remembers Jenn Chalifoux. She was 18 and on leave from college, at home in Long Island to receive treatment for anorexia, when she realized she was pregnant. Since a common side effect of anorexia is amenorrhea (a cessation of the menstrual cycle), missed periods didn't sound the alarm bell. She was surrounded by doctors, having blood work frequently, and on birth control. "It didn't even occur to me that I might [be pregnant]," she recalls. "My medical team thought my menstrual cycle would return as I progressed in my recovery." When it didn't, months into her treatment, Chalifoux took a pregnancy test at a friend's house. It came back positive and a follow-up appointment with her doctor revealed that she was well into her second trimester. It was a shock.
"Before, I didn't understand how people could overlook their pregnancy," she says. "It seemed ridiculous to me that you could be pregnant and have no idea; I thought all pregnancies looked the same, felt the same, and were instantly recognizable." Even so, Chalifoux had no doubt about the right course of action for herself. "I had just started taking antidepressants for the first time—and they were helping," she explains. "I'd drank a fair amount during my first trimester, before I knew I was pregnant. Alcohol and psychiatric medication are notably bad for fetal development. I'd also been losing weight during my pregnancy, which didn't bode well. Most importantly though, I didn't want to be pregnant. I needed partial hospitalization for my mental illness; the thought of carrying a pregnancy to term and then giving birth [gave me panic attacks]. I knew I wanted to have an abortion."
A Made-Up TermDeeply stigmatized and regularly reduced to a political rallying cry, later abortion is in fact a complex predicament—profoundly human, sometimes heartbreaking, and sometimes, surprisingly, hopeful. Often, it's exacerbated by misconceptions and bureaucracy. But when women are able to share the truth of their experiences and own the narrative, the results can be empowering—and often change the hearts and minds of those around them.
"A 'late-term' abortion is not a scientific or medical term—it's a made-up, political term," explains Diana Greene Foster, a professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco (UCSF), and the author of The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having—or Being Denied—an Abortion (Scribner Books, 2020). "A term pregnancy is 37 to 40 weeks—no abortions are happening so late. Very few abortions occur after 20 weeks (around one to two percent) and the number that occurs goes down dramatically each week. The term 'late-term' suggests that people are having abortions at the time of delivery, and that is not true." Foster also serves as director of research at Advancing New Standards in Reproductive Health (ANSIRH), a UCSF-based collaborative research group dedicated to better understanding people's sexual and reproductive lives. "Ninety percent of abortions occur in the first trimester," she says. "I call anything after that, 'later.'"
Over five years, Foster and her researchers interviewed 1,000 women from 30 medical facilities throughout the US and, whether they were successful in receiving an abortion or not, monitored their subsequent progress. Through personal narrative and data, Foster delves into the varied circumstances that lead women to seek abortion care, their access to it, and the long-term effects of those differing experiences. Foster's work provides one of the most complete and detailed pictures of abortion in America to date, including women who seek abortions after the first trimester, and why. While later abortions are only a small percentage of overall terminations, understanding their precipitating circumstances, and the interrelated issues, illuminates the reality of abortion in America today.
According to a CBS poll in June, 63 percent of Americans support legalized abortion in some cases, and a Marist poll last March found that 77 percent support the landmark abortion ruling Roe v. Wade. However, that support erodes to approximately 27 percent when polling includes later abortions. The Guttmacher Institute, a research and policy organization, reports that more than one-third of states have implemented 20-week abortion bans, and multiple states limit abortion in the second and third trimester. As of December 2020, 43 states placed limits on women's access to abortion after a certain gestational period. Fueling such decisions, the misconceptions surrounding later abortions abound, and the resulting stigma keeps many women silent about their experiences, further perpetuating the myths.
While Chalifoux's experience is rare, her reasons are common to women who need a later abortion. "When people have abortions in the second trimester, it's often because they didn't realize they were pregnant and then all the logistical, financial, and regulatory barriers to getting an abortion slowed them down," explains Foster. The masking of pregnancy symptoms, and irregular periods, can happen for a variety of medical reasons, including recent childbirth, polycystic ovary syndrome, certain medications, and even stress. Adolescents and perimenopausal women are especially susceptible. A study conducted by ANSIRH found that late recognition is often compounded by logistical delays in obtaining abortion care, setting off a chain of events that result in later abortions.
"Once I realized I was pregnant, everything was a race against the clock," remembers Chalifoux. "I had to research and call clinics in my area, and then I had to wait for the clinics to get back to me. I waited for the OBGYN, the sonogram, the hospital, the insurance company. The waiting was the worst part. I hadn't thought about how long it takes to get critical, nonemergency healthcare. Meanwhile, every day I was another day pregnant."
A Widening State DivideIronically, the need for a later abortion often arises from lack of access to more timely abortion care. "[Some] people seek abortion care later in pregnancy because they learned some new information they couldn't have known earlier—sudden life events like the death of a partner or loved one," says Erika Christensen, founder of the website Whonotwhen.com, which provides information and resources for understanding later abortion. "The other path to later care is being pushed by man-made barriers like clinic closures, inability to pay for an earlier procedure, and bans." Meanwhile, the divide for obtaining access is widening, as geographic bans and gestation limits fall on state lines. Recently, states such as Alabama, Missouri, and Ohio have effectively banned abortions after six weeks' gestation age, while states such as New York and Vermont have codified reproductive rights into state law. (In 2019, the passage of New York's Reproductive Health Act decriminalized abortion and lifted many of the existing restrictions on abortion care.)
Changes in the Supreme Court, tipping the balance toward conservative justices, indicate that the division between states will grow. "In the US, the number of places that don't have access to an easy abortion is extraordinary," says Nejla Lilas, president and founder of Global Health Visions, a Hudson Valley-based consulting organization dedicated to improving the lives and livelihoods of women and children. "Planned Parenthood of Greater New York has had to expand incredibly because they've seen so many people coming from other states as a result of emerging restrictions." Bans almost always heavily impact younger women with a lower income, and especially women of color. Institutional and systemic inequities abound.
As a woman's pregnancy progresses, the cost of abortion care increases, the access to abortions providers and reproductive services decreases, and restrictions become more common. If a woman is already the primary caregiver to young children, has an abusive partner, or even just has a full-time job, this lack of access can set off a chain of delays that often limits her reproductive access or denies it entirely. "The human body is complicated and doesn't follow legal timelines," adds Christensen. "But [man-made barriers] can be changed." Christensen advocates for abolishing abortion restrictions and repealing the Hyde Amendment (which restricts the use of federal funding for abortions) so that people can use insurance to pay for abortion care.
Christensen's own heart-rending experience of needing an abortion at 32 weeks inspired her to start Whonotwhen.com as well as the patient advocacy site Patientforward.org. It was during her second trimester of pregnancy that she and her husband Garin Marshchall realized that her pregnancy wasn't viable. The fetus had muscular issues and wasn't growing or swallowing. In her third trimester, doctors told her she would most likely give birth to a child who would only live a few hours. She and Marschall wanted to alleviate any suffering as best they could and stay true to their morals and values. Yet, because of New York's previous gestational limits, their options were limited. The couple decided to fly to Colorado so that Christensen could receive an injection to terminate her pregnancy, then flew back to New York to deliver the stillborn.
Trusting a Woman's Decision-MakingDeeply personal and specific, the choice to have an abortion is never easy—yet Foster's study indicates that we should trust a woman's decision-making in seeking abortion care. "All the reasons women give for wanting an abortion are evident in the experiences of women who are denied," explains Foster. "If a woman is concerned about financial security, they become poorer when they are denied an abortion. If they say their relationship is not strong enough to support a child, the relationship dissolves whether they receive an abortion or not. When they say they want to take care of the children they already have, we see that their existing children do worse when they are denied an abortion." Meanwhile, the health risks of carrying an unwanted pregnancy to term are not fully understood. "In the study, two women died of pregnancy related complications because they were denied an abortion," says Foster. "No woman died from receiving one."
When women are given access to abortion care, even during the later stage of their pregnancies, they tend not to regret it. According to the Turnaway Study, 95 percent of women who have abortions feel it was the right decision. Children also benefit from expanded reproductive rights. "When women are able to get a wanted abortion, they are more likely to be able to take care of the children they already have, and to have intended pregnancies in the future," says Foster.
In the end, it's compassion, and a network of nonjudgmental support, that truly benefits people who seek later abortions. "Most people would be surprised to know how loving and specific the later abortion world is," says Christensen, who now with Marschall has a daughter. "We're talking about the incredible, radically empathetic doctors and staff working at last-stop/later clinics, the complicated web of practical support organizations that help patients pay for the care itself, and the travel to get there. Meeting people from all walks of life who have traveled the same path to access care that is both incredibly uncommon and wildly stigmatized is also very healing."
Chalifoux, whose experience with later abortion is now 10 years behind her, recalls the unconditional support from family that carried her through an incredibly difficult time. "I'm so lucky to have parents who immediately wrapped their arms around me and promised to help," she explains. "Once I involved them, I knew for sure that I'd be okay." Now engaged and looking forward to starting a family, Chalifoux has no doubt that her access to a later abortion saved her life. "When I see support for gestational limits, I see people who want to prevent other people like me from accessing life-saving healthcare," she says. "But I believe wholeheartedly that I would not be alive today if I'd given birth. My life today is full of love and joy."