The most common abortion procedures and when they occur

New research by the Guttmacher Institute, a nonprofit research organization that supports abortion rights, suggests the long-term decline may be reversing, with an increase in 2020.

Nearly 1 in 4 women in the United States will have the procedure by the age of 45, according to an estimate from the Guttmacher Institute. The group estimates that 18 percent of U.S. pregnancies end in induced abortions.

Most abortions happen in the first trimester. In 2019, nearly 80 percent of the procedures reported to the CDC were performed before the 10th week of pregnancy. Almost 93 percent were performed before the 13th week.

There are two ways an abortion can be done. Medical abortion ends a pregnancy through the use of medication. Surgical abortion, sometimes called procedural abortion, ends a pregnancy through a procedure performed by a health-care provider in a clinical setting.

Whether a patient gets a surgical or medical abortion comes down to factors including the stage of pregnancy, the patient’s preference and state restrictions, experts said. Both are safe and effective, said obstetrician and gynecologist Nisha Verma, a fellow at the American College of Obstetricians and Gynecologists.

“Some of my patients prefer the abortion procedure, knowing that when they leave my care, they are no longer pregnant,” she said. “Others prefer to be able to take the pills needed for medication abortion in the comfort and privacy of their own home.”

Surgical and medical abortions can be done in both the first and second trimester. According to 2019 CDC data, surgical abortions mostly occurred in the first 13 weeks. The majority of medical abortions were done within the first nine weeks.

Abortion via medication is a newer method that has become increasingly common in the United States for first-trimester pregnancies.

It is most commonly done using a pill called mifepristone, which is taken in combination with another medication, misoprostol. Developed by French researchers in 1980 and approved for use in France in 1988, mifepristone gained long-sought U.S. Food and Drug Administration approval in 2000.

Since then, the percentage of abortions performed using medication has rapidly grown. The Guttmacher Institute estimates that by 2020, more than half of U.S. abortions were medical.

The pandemic is believed to have accelerated the trend. The FDA began allowing abortion pills to be mailed to patients in April 2021, waiving a long-standing requirement that they be dispensed only in health-care settings, and the Biden administration made the change permanent months later.

“What we’ve been watching over the past 10 years is medical abortion increasing and increasing and increasing,” said Cassing Hammond, an OB/GYN and associate professor at Northwestern University’s medical school.

Types of medical and surgical abortions

Abortions generally become more expensive and more difficult to access the further along a pregnancy is, said Jen Villavicencio, an OB/GYN in the D.C. area who oversees equity initiatives at the American College of Obstetricians and Gynecologists. A first-trimester abortion typically costs around $500, while a second-trimester abortion costs between $750 and $2,000.

While Roe protects abortion across the United States, the current Supreme Court standard allows states to ban it after the point at which a fetus can survive outside the womb, as long as exceptions are made for the life and health of the pregnant patient.

The viability of a fetus is determined on a case-by-case basis. It is generally understood to be reached around 24 weeks and sometimes as late as 28 weeks. In all, 44 states prohibit some abortions after a certain point in pregnancy, according to the Guttmacher Institute.

Third-trimester abortions are rare and heavily restricted. Just 1 percent of abortions take place after 21 weeks; the third trimester begins around the 28th week.

“When abortions occur in the third trimester, most often something has gone terribly wrong in the pregnant person’s life or pregnancy,” Villavicencio said.

In a first-trimester medical abortion, a patient usually begins by taking a mifepristone pill. The medicine, also known as RU-486 or the “abortion pill,” blocks the hormone progesterone, which stops the fetus from growing.

The second drug, misoprostol, is usually taken 24 to 48 hours later. It causes the uterus to contract and empty.

The two-drug protocol has FDA approval for use up to the first 10 weeks of pregnancy and is generally used in that timeline. After the FDA’s removal of the in-person dispensing requirement last year, the medication can be distributed by certified pharmacies through the mail in some states.

Many states, however, have passed restrictions on the use of mifepristone for abortions.

Thirty-two states allow only licensed physicians to dispense the pills, according to the Kaiser Family Foundation. Seven — Arkansas, Idaho, Kentucky, Nebraska, Oklahoma, South Dakota and Utah — require patients to be told that abortions by mifepristone can be reversed with doses of progesterone, despite a lack of scientific evidence.

A first-trimester surgical abortion is called vacuum or suction aspiration.

A suction device is used to empty the uterus in a procedure that can be done in five to 10 minutes. But between counseling, preparation and recovery time, a patient can expect to spend several hours at the appointment.

Vacuum or suction aspiration is typically offered between six and 12 weeks of pregnancy, though some providers may offer it a little earlier or later.

A second-trimester surgical abortion is called dilation and evacuation.

For this type of abortion, the process of dilating the cervix may need to begin the day before the procedure.

On the day of the procedure, a numbing agent may be given, or sedation may be offered. A health-care provider uses forceps and a suction device to remove the fetus and placenta.

The procedure itself usually takes between 10 and 30 minutes, with a few additional hours for counseling, preparation and recovery. It is done in a clinic or operating room.

Dilation and evacuation can generally be performed throughout the second trimester of pregnancy. It accounts for an estimated 95 percent of abortions performed in the second trimester in the United States.

Several states have sought to ban abortions by dilation and evacuation, though many attempts are facing court challenges and not in effect, according to the Guttmacher Institute. Bans are in effect in Nebraska, Mississippi and West Virginia, the organization said.

A second-trimester medical abortion is called an induction.

Medication is given to induce labor by causing the uterus to contract and expel the fetus and placenta.

Different medications can be used, including a combination of misoprostol and mifepristone, or misoprostol alone. In some cases, high-dose oxytocin is delivered through an IV. Medicine to relieve pain is also usually provided.

The process can take 12 to 24 hours and generally occurs in a hospital.

Induction abortions mostly take place after 16 weeks and can be used throughout the second trimester.

This type of abortion results in an intact fetus. A patient who wants to see and hold the fetus may prefer this method, Hammond said. Induction may be the chosen method in cases of fetal abnormalities because an intact fetus can be beneficial for diagnoses that may inform future pregnancies.

Induction abortion is less common than dilation and evacuation, but one study found it is the primary method of termination in cases of fetal abnormalities in the late second trimester and early third trimester.

Third-trimester abortions are performed in only a handful of clinics and hospitals in the United States, according to the American College of Obstetricians and Gynecologists. Methods for third-trimester abortions vary based on the circumstances. They usually involve a combination of medication and surgical procedure and can take several days.

What isn’t abortion

Confusion sometimes crops up over what is and is not abortion. Abortion is a medical intervention that ends a pregnancy. Pregnancy begins when a fertilized egg implants in the uterus, according to the American College of Obstetricians and Gynecologists. Methods used to prevent pregnancy before it occurs are called contraceptives.

The morning-after pill is an emergency contraceptive that primarily works by stopping the release of an egg from an ovary but may also prevent implantation of a fertilized egg. It is taken orally. The over-the-counter version, sold under brand names including Plan B, is generally taken within three days of intercourse, and the prescription version, Ella, can be taken within five days of intercourse. It is not the same as mifepristone, the pill used in abortion.

An intrauterine device (IUD) is a contraceptive that works mainly by reducing sperm’s ability to fertilize an egg. There are two types: copper and hormonal. In copper IUDs, copper ions decrease sperm’s ability to move. In hormonal IUDs, progestin thickens mucus in the uterus, making it harder for sperm to enter the uterus and reach an egg. A hormonal IUD may also prevent implantation.

An IUD is placed into the uterus by a health-care worker and can remain in place for five to 10 years, depending on the type.