INTRODUCTION

Throughout the world, policies restricting and banning abortion care disproportionately impact systematically oppressed communities already facing higher rates of maternal mortality and chronic disease, including communities of color and low income communities that have survived systemic harms (Bearak 2022). Young people, those who face language barriers including immigrants and refugees, people with disabilities, and gender diverse people face additional unique challenges to accessing healthcare, especially abortion care. All efforts to increase abortion access should embrace a reproductive justice model to ensure excellent, person- and community-centered care (See Ch 1: Reproductive Health through a Justice Lens).

Second trimester abortions comprise approximately 10-15% of abortions globally and 9% in the U.S. (Korsmit 2018). Poverty, lower education level, and multiple disruptive life events have all been associated with people seeking abortion beyond 14 weeks (Jones 2012). In the post-Dobbs U.S., 41 states ban abortion at some point in pregnancy, so the term “later” often depends on where a person lives (WhoNotWhen). Travel-related logistical issues, financial issues, challenges navigating the system, and limited appointments at overburdened health centers all lead to delays in abortion care (Kimport 2022, Jerman 2017). “It is still unknown whether this has led to an increase in the share of abortions that are performed later in pregnancy” (KFF 2024).

Common reasons providers may limit abortion care to 12-14 weeks gestation include lack of advanced training opportunities, stigma, legal restrictions, staffing (including ability to provide intra-procedure ultrasound and anesthesia), and concerns for increased complications. Trainees face limited procedural abortion training opportunities, and barriers to practice integration (See Ch 9: Landscape and Limitations). Abortion bans have intensified these challenges by prompting health center closures, funneling care into the vastly fewer remaining health centers.

One response to restrictions is incremental expansion of procedural abortion provision in legal settings. Expanded offerings can have a significant impact on access and travel, particularly in rural areas. For example, expanding abortion provision by just 2 weeks gestation (from 14 weeks to 16 weeks) at Maine’s northernmost abortion health center was estimated to decrease by half the number of people with pregnancies “too far along” that would have required referrals 100-250 miles away (McDonald 2018). Multiple U.S. studies have examined increasing distances traveled by people from hostile states to access abortion care (Bettelheim 2024, Rader 2022).

Abortion care >14 weeks can be completed following cervical preparation with uterine aspiration alone or dilation and evacuation (D&E), or medication alone.

• Uterine aspiration alone uses a combination of cervical preparation with large-bore tubing only. Aspiration may be adequate through 16 weeks gestation, after which time it is often necessary to use forceps.
• D&E uses a combination of suction and grasping forceps to remove the pregnancy.
• Medication abortion uses misoprostol with or without mifepristone, and is safe and effective >14 weeks with the proper medication protocols (WHO 2022).

Person-centered care, preference, resources, and healthcare team knowledge and skills should be considered when deciding which method of abortion care to provide. D&E can offer more predictable timing, safety, and cost savings compared to induction with misoprostol (ACOG 2013). Medication abortion should be considered for people who prefer to avoid a procedure and/or prefer an intact fetus (e.g. for emotional closure), although location of abortion and management of fetal remains need to be considered. Medication abortion may be more feasible in settings where providers lack training in D&E or aspiration, where restrictions limit its use, or where sterility cannot be guaranteed (Guttmacher 2023).

This resource is written for clinicians proficient in abortion care to 12 – 14 weeks gestation, assumes standard practices discussed throughout this curriculum, and represents common practice in abortion provision from 14 – 18 weeks gestation. The techniques described in this chapter, such as initiating cervical preparation in same day procedures, becoming comfortable with using US guidance during dilation and aspiration, and starting to use forceps can be gradually employed to increase confidence and skill. Incremental expansion is a low-barrier way for providers to feel comfortable with increasing gestational duration. Beyond 18 weeks, more time and advanced skills are typically required for procedural abortions, including longer cervical preparation time with some combination of: misoprostol, mifepristone, osmotic dilators, foley bulbs, inducing feticide prior to the abortion, and/or more frequent use of forceps for larger and more calcified parts.