INTRODUCTION

Throughout the world, political agendas restricting and banning abortion care disproportionately impact traditionally marginalized communities already facing higher maternal mortality and chronic disease, including communities of color and low income communities. These communities have survived systemic and historical harm imposed by a white-centered practice of medicine. Young people, those who face language barriers including immigrants and refugees, and gender diverse patients face additional unique challenges to accessing healthcare, especially abortion care. All efforts to increase access should embrace a reproductive justice model to ensure excellent, community-centered care. (See Ch 1: Reproductive Health through a Justice Lens)

Poverty, lower education level, and multiple disruptive life events have all been associated with patients seeking abortion beyond 14 weeks. (Jones 2012) Globally, second trimester abortions comprise approximately 10-15 percent of abortions, compared to 9% in the U.S. (8% between 14-20 weeks and 1% beyond that). (Korsmit 2018) Twenty four U.S. states have or are likely to ban abortion since the Dobbs decision. (Guttmacher 2023) Unless pregnant people in these states can self-manage or travel to “haven” states, they will lose access. Travel-related logistical issues, financial issues, challenges navigating the system, and limited appointments at overburdened clinics – all lead to delays in abortion care (Bearak 2022, Kimport 2022, Jerman 2017). While medication abortion accounts for over half of recent U.S. abortions (Guttmacher 2022), new restrictions on gestational limits, legal challenges to mifepristone, COVID-era telemedicine funding expirations, and urgency to complete abortions for patients returning to hostile home states all complicate access.

Common reasons providers may limit abortion care to 12-14 weeks EGA include lack of advanced training opportunities, legal restrictions, and concerns for increased complications. Trainees face limited procedural abortion training, as well as barriers to practice integration. (See Ch 9: Landscape and Limitations) Abortion bans have intensified these challenges by eliminating training in hostile states, prompting clinic closures, and flooding overburdened haven state clinics.

One response to abortion restrictions is incremental expansion of procedural abortion provision in haven states. Expanded offerings can have a huge impact on patient access and travel, particularly in rural areas. For example, expanding abortion provision by just 2 weeks gestation (from 14w to 16w) at Maine’s northernmost abortion clinic was estimated to decrease by half the number of patients with pregnancies “too far along” that would have required referrals 100-250 miles away. (McDonald 2018) Multiple U.S. studies are examining increasing distances traveled by patients from hostile states to access abortion care.

Second trimester procedures are most often performed procedurally, with dilation and evacuation (D&E), uterine aspiration alone, or medication induction.

• D&E uses a combination of cervical preparation and grasping forceps to remove a pregnancy, and offers more predictable timing, safety, cost savings, and patient preference compared to medications induction. (ACOG 2017, Paul et al (eds) 2009)
• Uterine aspiration (without forceps) with large-bore tubing may be adequate through 16 weeks EGA, after which time it is often necessary to use forceps.
• Medical induction may be considered for patients who prefer to avoid surgery, prefer an intact fetus (e.g. for autopsy after demise), and are willing to accept more time, awareness, and discomfort during the process. Medical induction may be chosen in settings where few providers are trained in D&E, where restrictions limit its use, or where sterility cannot be guaranteed. (Guttmacher 2023, Paul et al (eds) 2009)

This resource is written for clinicians proficient in abortion care to 12 – 14 weeks EGA, assumes standard practices discussed throughout this curriculum, and represents common practice in abortion provision from 14 – 18 weeks EGA.