Psycho-Social Aspects of Late Term Abortions

Association for Interdisciplinary Research in Values and Social Change
Vol. 14, No. 4 January/February, 2000
Thomas W. Strahan, B.S., J.D.
Reproduced with Permission

According to the Centers for Disease Control, induced abortions at 13 gestational weeks or more represent 11.7% of all abortions in the U.S. in 19961 but it is a subject that is not frequently studied. However, the second trimester is an important developmental stage for the unborn child. Quickening occurs anywhere from 16-22 gestational weeks where the pregnant woman can feel the baby kicking and viability occurs late in the second trimester at 22-24 gestational weeks when the child is capable of living independently outside of the womb. There have also been numerous reports of successful fetal surgery in the second or third trimester. Ominously, it is also the gestational stage where partial birth abortions take place. Also, teenage abortions as well as abortions for fetal anomaly or pregnancies from rape or incest are more likely to occur in the second trimester. Despite its relative infrequency, it is important to note that about 143,000 second or third trimester abortions occurred in the U.S. in 1996 out of the slightly more than 1.2 million reported by the Centers for Disease Control. Hence, it is an important subject.

Late term abortions are
more unacceptable to the
general public.

Abortion occurring after the first trimester for medical or social reasons is also more unacceptable to the public compared to first trimester abortion. A 1990 national Gallup poll commissioned by the Americans United for Life found that 28% of those polled would accept a first trimester abortion if the pregnancy would require a teenager to drop out of school, but only 15% found abortion acceptable for the same reason if it would occur after three months gestation. Similarly, 55% would accept a first trimester abortion if the woman's mental or emotional health might be damaged by the pregnancy, but only 33% would accept abortion for the same reason if abortion would occur after three months gestation. Abortions for other medical and social reasons showed similar trends.2

I. Women Obtaining Late Term Abortions are a Special Population

Women who have induced abortions at 16 gestational weeks or later (5.8% of U.S. abortions) are a special population according to a 1987 survey by the Alan Guttmacher Institute of 420 women seeking abortions at various abortion facilities throughout the United States. According to the survey, these women are significantly more likely to be teenagers under the age of 18 (Table 1), black women (Table 2), unemployed women, or women covered by Medicaid. Abortions at 16 gestational weeks or more are also more apt to be performed if the reason was possible fetal health problems, if the womans parents wanted her to have an abortion, or if the pregnancy resulted from rape or incest. Women were significantly less likely to have a later abortion if they were age 30 or older, if they had no religious affiliation, if they were having health problems, or if their husband or partner wanted them to have an abortion.3

Table 1
Reported incidence of late term abortions by age and percent
distribution by period of gestation: 14 state area, 1988
Age of Women No. of Abortions 13-15 weeks 16-20 weeks 21 weeks or more
Under 14 years62613.7%10.3%4.3%
14 years173711.7%9.6%3.7%
15 years453310.2%7.4%2.7%
16 years93069.86.72.5
17 years145069.15.61.9
18 years209637.74.71.4
19 years209217.44.41.4
20-24 years964336.33.71.2
25-29 years643415.22.91.0
30-34 years367314.12.50.8
35-39 years181863.62.70.8
40 and over50193.52.71.0
Not Stated39496.25.11.6
The 14 state area includes: Colorado, Indiana, Kansas, Maine, Missouri, Montana, New York, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Vermont, and Virginia; Source: Induced Terminations of Pregnancy: Reporting States, 1988, KD Kochenek, National Center for Health Statistics, Monthly Vital Statistics Report Vol 39, No. 12, Supplement, April 30, 1991, Table 2, Table 11

Moral Conflicts

A substantial number of women who obtain late term abortions would be opposed to abortion on moral grounds. This would particularly apply to religious women, black women, and low income women. A 1981 nationwide poll commissioned by the Connecticut Mutual Life Insurance Company asked, " Do you believe abortion is morally wrong, or is it not a moral issue." Overall, 67% of females compared to 64% of males believed it was morally wrong. Among those with the lowest religious commitment, only 43% thought it was morally wrong compared to 75% with moderate religious commitment or 85% among those with the highest religious commitment. Blacks were more likely than whites to believe abortion is morally wrong (73% v. 64%). Among those with incomes under $12,000, 74% believed abortion was morally wrong compared to only 56% among those with incomes above $25,000.4

Women with moral objections
are more likely to have
a late term abortion

Similar results were obtained in a 1989 Los Angeles Times national survey which asked, "Do you believe abortion is morally right or morally wrong?" Overall, 61% of those polled believed abortion was morally wrong including 34% of those who favored legal abortion, 37% of women who had prior abortions, and 88% of those opposed to legal abortion. Those with less education or lower incomes were more likely to believe abortion is morally wrong compared to those with more education or higher incomes.5 Women with moral objections to abortion have also been found to be more likely to have a late abortion compared to an early abortion. These moral conflicts included opposition of the woman to abortion as well as conflicted decisions.6

Attachment to Unborn Child

Women who have abortions in the second trimester have been found to be more likely to use the word "baby" in describing what is in her womb compared to women who have abortions in the first trimester who are more likely to use words such as "this pregnancy" or "this condition."7 Another study found that pregnant women at more than 16 weeks gestation were much more likely to carry to term if they requested and were denied an abortion compared to women who were at 16 weeks gestation or less.8


Various studies have found that women who obtain abortions in the second trimester have significantly different behavior patterns compared to women obtaining abortions in the first trimester. High levels of indecision and ambivalence have been found in women undergoing mid trimester abortions compared to women having first trimester abortions.9 Researchers at the University of California concluded that "women who delay the decision to abort have a background of greater psychopathology and have difficulty in decision making. They often lack social supports and have difficulty with contraception."10 Researchers at the Yale University School of Medicine found that those who delayed seeking abortion until the second trimester frequently kept news of the pregnancy from partner and parents, and did not obtain financial help, or refused it when offered. They also found that those who waited until the second trimester were often ambivalent about seeking the abortion and, to a lesser degree, were unwilling to accept the possibility of pregnancy.11


Psychological immaturity was identified as one of the important factors in delayed abortion in a Washington D.C. study of 1066 women having easy access to late term abortion.(6) The 1987 Alan Guttmacher Institute survey also found that women under the age of 18 are significantly more likely to obtain abortions at 16 gestational weeks or later compared to women who obtained abortions in the first trimester.(3)


The 1987 Alan Guttmacher Institute survey found that women were significantly more likely to have an abortion at 16 gestational weeks or greater if her parents wanted her to have an abortion.(3) Another small study reported that women were more likely to present for second trimester abortion after some peer pressure compared to women having first trimester abortions.(7) High levels of conflict over the decision to seek an abortion can delay the decision to have an abortion. Low levels of support from others also increases the level of conflict over the abortion.(11)

Table 2
Number of reported late term abortions by race of woman and
percent distribution by period of gestation: Reporting States, 1996
Period of Gestation White Black Hispanic Other Races
13-15 weeks5.5%7.0%6.3%5.2%
16-20 weeks4.
21 weeks or more11.0%14.2%12.3%11.7%
Source: Koonin et al, Abortion Surveillance -- United States, 1996,
MMWR 48/No.SS-4, Table 16, July 30, 1999

Difficulty in Making Arrangements

The 1987 Alan Guttmacher Institute (AGI) survey found that difficulty in making arrangements for the abortion was an important reason for delay. This included time to raise money, going to more than one facility, arranging transportation or not knowing where to go.(3) Another study found that women frequently waited until the last minute before seeking a pregnancy test because they did not want to admit being pregnant until it was almost too late to obtain an abortion.12

Biological Factors

A history of irregular periods was found to be the strongest single predictor for women seeking late abortions in a multiple regression study of Washington D.C. women, although much of the variation in gestational age at the time of abortion was not explained by the analysis.(6) This uncertainty is presumably related to the tendency of women seeking late term abortions to wait longer to seek confirmation of the pregnancy. Another study found that not knowing soon enough the gestational age of her pregnancy was an important factor among women obtaining abortions at 16 gestational age or more.(3)


According to the 1987 Alan Guttmacher survey almost two thirds (63%) of U.S. women who have abortions as teenagers at 16 weeks gestation or more, and one-third of the overall sample attributed the delay to being afraid to tell their partner or parent that they were pregnant.(3) Another study of postabortion women where women frequently had second trimester abortions at a young age, reported that abortion was utilized as a strategy for coping with the pregnancy without ever fully admitting that the pregnancy existed.(12)

Low Self Esteem/Identity Conflicts

Poor ego strength and low self-esteem was found among women undergoing second trimester abortions at a Planned Parenthood of San Francisco facility.(7) Another study of New York City women found that abortion at later gestational ages was significantly associated with a greater disturbance of the basic sense of self due to gender/sexual conflict and lower levels or internalized striving or ambition.13

Lack of Social and Economic Resources/Inability to Receive Offers of Assistance

The 1987 Alan Guttmacher Institute survey of women who obtained abortions at 16 gestational weeks or later found that unemployed women and women receiving Medicaid were more likely to have later abortions compared to women who had first trimester abortions.(3) Researchers at the Yale University School of Medicine found that it was characteristic of women who delay abortions not to obtain financial help or to refuse it when offered.(11) Other researchers have found that women who obtained second trimester abortions often lacked social supports and spoke more often of assessing the resources available to help them keep a child compared to women with first trimester abortions.(7)(10)

Non-Use of Contraceptives

Researchers have found that women who obtain second trimester abortions do not use contraceptives, or use contraceptives to a lesser degree compared to women obtaining first trimester abortions. Researchers at the Yale University School of Medicine concluded that, "available studies suggest that unprotected coitus correlates with delay in seeking an abortion."(11) The Washington D.C. study which used multiple regression analysis to determine what factors are related to the gestational age at which women seek an abortion found that contraceptive use predisposed to early abortion to a significant degree.(6)

Influence by Doctors or Genetic Counselors

Doctors and other professionals may encourage abortions if there is a possibility that the baby would be born with a handicap. They also may reinforce the parent's fear that they may not be equal to the task if a handicapped child were born, or because they believe that a special needs child would be too great a financial burden.14 Prenatal diagnosis can be very stressful and can provoke a host of psychological responses, including shock, anxiety, depression, shame, and guilt.15 Moral, religious, or philosophical concerns may predominate.16 If there is a crisis, a minimal amount of effort by a counselor or doctor, can exert a maximum amount of leverage on the stressed individual.17

Pregnancy Resulting from Rape

The 1987 Alan Guttmacher survey also found that women who had been raped and became pregnant as a result were more likely to have a second trimester abortion of 16 gestational weeks or more compared to women who had abortions at an earlier gestational age.(3) A national study by researchers at the Medical University of South Carolina of women age 1245 who became pregnant following rape reported that 32.4% of the women did not discover they were pregnant until they were in the second trimester. Of those who became pregnant, 32.2% carried to term and kept the infant, 50% underwent abortion, 5.9% carried to term and placed the infant for adoption, and 11.8% had spontaneous abortions.18

One study explored pregnancy arising from rape including the factors or conditions which made it most difficult for women to continue the pregnancy to term. Responses of the women included family pressure, the women's belief that people would not believe she was raped, and the boyfriends attitude. Other responses included the pregnancy as being a continual reminder of the rape event; fear, anger or hate of the baby's father; and negative feelings about herself including guilt or low-self esteem.19

II. Initial Reactions of Women and Abortion Facility Personnel to Various Second Trimester Procedures

A small study of women who had abortions at Planned Parenthood of San Francisco in 1971 compared women who obtained first trimester abortions with those who obtained second trimester abortions by amniocentesis. At one week postabortion, it was reported that the women who had first trimester abortions generally had positive responses, while the second trimester group had considerably different responses. Women with second trimester abortions often stated that they had not been adequately prepared for the amniocentesis and tended to use such term as "labor", "delivery", and "childbirth."

Women having second
trimester abortions were
more attached to the
unborn child

Emotions were mixed among the second trimester group and a pattern of denial was observed which often extended to the hospitalization with focus on the physical facilities. These women spoke of "emptiness" with one woman saying, "It's like having a baby, but not being able to keep it." Despite their initial cooperation in the study, it was reported that further follow-up was not possible because they were a highly mobile group who seemed anxious to close out the abortion experience.(7)

Another long term study of 30 women who reported to be highly stressed by the abortion experience found that specific manifestations of stress were influenced by the type of abortion procedure. Women who underwent second trimester saline abortions reported that the labor was prolonged and painful. Women experienced a great deal of recrimination and remorse as they went through the process of aborting a fetus that was premature but fully formed. Those who saw the aborted fetuses were shocked by the burns caused by the saline and the horror of what looked like a small baby. None thought they had been adequately prepared for the event. Stress and immediate remorse occurred during the induction of the saline, at which time the fetus began a struggle for life. Violent kicking and punching on the part of the fetus, as its amniotic sac was filled with caustic saline solution, was psychologically unbearable to the women. The following remarks indicate how unprepared the women were:

" ... And the minute the salt goes in, the baby goes into convulsions, inside you can feel it flopping around in there, just fighting for life."

" ... the whole ward.... the women were screaming and crying to keep their babies. And it was like they were screaming for mercy and saying life. 'Oh God please help me' and 'God forgive me' and they were just screaming out, and they were saying, 'I am sorry' and things like 'I want my baby.'"(12)

With other second trimester abortion procedures such as dilatation and curettage (D&C), or dilatation and evacuation, or dilatation and extraction, women may not have the same emotionally charged reaction to the procedure as a saline abortion. The use of mechanically induced second trimester abortions, such as dilatation and extraction (D&E) under general anesthesia has been found to reinforce existing denial among women at the time of the abortion. In a study of 250 women who had undergone mid trimester abortions by dilatation and extraction under general anesthesia and who were interviewed three weeks postabortion, D&E was seen as helpful in getting through an ambivalent situation and which tended to reinforce preexisting denial. The use of general anesthesia led to an experience which was described by the women as "like a dream" and "out of my hands". The researchers found that women who had a D&E abortion were consciously aware of avoiding the implications of the procedure and rarely asked any questions.(10)

Although denial may occur at the time of the abortion and last for a period of time, it eventually can break down and women may express a high level of chronic stress from the experience. Among the long term stresses women may experience from D& E abortions, include anxiety regarding pain the fetus may have experienced, and guilt over the knowledge that a second or third trimester fetus had been dismembered.(12) Some women who undergo a D&E abortion under general anesthesia will not be in denial, but instead will almost immediately experience its painful reality. One 40 year old woman who had an abnormal amniocentesis indicating Down Syndrome decided upon a D&E abortion at 20 weeks gestation under general anesthesia. Although the D&E took about 15 minutes and was painless, her grief was overwhelming. She said: "I have had to face the fact that I felt the baby kicking as I walked into the abortion clinic. I have had to face images of blood and death, and of a fetus in pieces... I cried and cried and cried about this... The actual loss of my baby continues to hurt and haunt me.20

Although the D&E procedure under general anesthesia or sedation may allow women to be in denial, it has been found to be extremely stressful on many doctors and abortion facility staff workers. One doctor who did second trimester abortions by the intra-amniotic injection of prostaglandin but would not perform D&Es said, "Killing a baby is not a way I want to think about myself." It was reported that two doctors who did all of the D&Es in the study supported each other and relied upon a strong sense of social conscience founded on the health and desires of the woman. They felt technically competent but had strong emotional reactions during or following the procedures and occasional disquieting dreams.(10)

"Killing a baby is not
a way I want to think
about myself."

Another study examined the emotional reactions of abortion facility staff to D&E abortions up to the 23rd menstrual week of gestation. Reactions to the fetus ranged from purposely not looking at it, to shock, dismay, amazement, disgust, fear, and sadness. Attitudes toward the doctor included sympathy, wonder at how he could perform a D&E at all, and a desire to protect him from trauma. Many reported serious reactions that produced physiological symptoms, sleep disturbances, effects on interpersonal relationships, and moral anguish.21

Other abortion facility workers become adjusted to late term abortions. In an interview with a Seattle nurse who saw her first late term abortion done by dilation and evacuation she said. "I was watching the doctor struggle with the cannula, trying to pull it out. I didn't understand what the resistance was all about. And I was very alarmed and all of a sudden the doctor pulled the cannula out and there, as I was at the woman's side, I looked down at the cannula and there was a foot sticking out. I will never forget the feeling I had in my chest as the doctor pulled that cannula out. And it almost took the breath out of me. Because the reality of this was very hard for me." The nurse said it took weeks for her to process the issue. "This sounds terribly cavalier, I suppose, but within about a month, like everything else we do after a while, it becomes pretty routine and it has never bothered me since then."22

Next Page: III. Psychological Reactions
1, 2