WASHINGTON - President Donald Trump in his State of the Union address on Tuesday called on Congress to make late-term abortions illegal. His characterizations of the procedure and recent state legislative efforts were misleading, but the comments highlight a shift in the conversation about abortion in recent years.
The focus of the debate has moved from reproductive freedom to how to balance the rights of a pregnant woman against those of her fetus. And nowhere is this change more apparent than in Americans' ambivalent feelings about abortions that take place later in pregnancy.
Abortions after 21 weeks are rare -- only about 1.3 percent of all abortions -- and despite all the divisive rhetoric sparked by legislative efforts in Virginia and New York to loosen restrictions on women seeking the procedure, late-term abortions are where "pro-choice" and "pro-life" coalitions begin to fragment and find common ground.
A Gallup poll conducted in May 2018 found that a clear majority of Americans -- 60 percent -- believe abortion should be legal in the first trimester. But support falls to 13 percent when they are asked about the third trimester.
But some late-term abortions are conducted to protect the life or health of the pregnant woman, which some abortion foes accept. The National Right to Life Committee, for example, has said exceptions could be made if an abortion is needed to save a woman's life.
"We have never said she has to die if her life is in danger," National Right to Life President Carol Tobias said on Tuesday. However, she said the group makes a distinction between a threat to a woman's life and a risk to her health, which they do not consider a reason for abortion.
Jen Villavicencio, a physician in the Midwest, used to oppose abortion. She's now a member of the American College of Obstetricians and Gynecologists, which holds that abortion is part of comprehensive care for women. Villavicencio said she has been frustrated by the black-and-white rhetoric among politicians, and believes it does not represent the compassion many Americans feel toward women facing a decision about whether to terminate their pregnancies at a late stage.
"If I'm being completely honest both sides are putting this into boxes -- I'm right and you're wrong. But you can recognize you feel uncomfortable with later abortions, but OK with women accessing the care for themselves and their families," Villavicencio said.
Medical advances have made this conflict more acute. When the Roe v. Wade decision was handed down by the U.S. Supreme Court in 1973, it emphasized the concept of fetal viability -- the point at which a fetus might be able to survive outside the womb -- and that a woman's right to an abortion was not absolute. It gave states the right to restrict abortion after that time as long as there are exceptions for the endangerment of a woman's life or health. Today, 43 states restrict abortions after some point in pregnancy, according to the Guttmacher Institute, a nonprofit research center that supports abortion rights.
The timing of fetal viability has changed. Forty-five years ago it was around 24 to 28 weeks. It's currently accepted to be closer to 22 to 26 weeks. Justice Sandra Day O'Connor predicted this shift, commenting that Roe v. Wade was "on a collision course with itself."
The earliest-term baby known to survive was born at 21 weeks and 4 days of gestation. The girl, born in San Antonio to Courtney Stensrud, weighed a mere 0.9 pounds. Her skin was see-through, her lungs underdeveloped, and her eyes unable to focus. Obstetric guidelines do not recommend doctors resuscitate in this situation, but Stensrud asked them to try. Writing in the journal Pediatrics in December 2017, her doctors reported she had grown in to a healthy 2-year-old toddler but cautioned that this doesn't mean all babies born at this stage of development could be saved.
The largest study of women who have undergone abortions later in their pregnancies was conducted at the University of California, San Francisco by Diana Greene Foster and Katrina Kimport. The research is unusual because it has been cited both by those who support abortion rights and those who do not.
Known as the Turnaway study because of how some women were "turned away" from clinics due to how far along their pregnancy was, it involved nearly 1,000 women at 30 facilities who sought abortion when they were 20 weeks along or later, for reasons other than their lives being endangered or a medical problem with the fetus. The study compared outcomes for those two groups and also compared women who had abortions early or relatively late in gestation. Participants were interviewed by phone regularly over five years, ending in December 2015.
One of their first papers, published in 2013, found that the women who had later abortions were similar in race, ethnicity and mental and physical health history to women who had abortions earlier. But they were younger and many experienced what they called "logistical delays," such as finding an abortion provider, raising the funds for the procedure and travel costs.
"Most women seeking later abortion fit at least one of five profiles: They were raising children alone, were depressed or using illicit substances, were in conflict with a male partner or experiencing domestic violence, had trouble deciding and then had access problems, or were young," they wrote.
Other studies compared women at similar later stages of pregnancy who were able to obtain abortions and those who weren't, and found big differences in their outcomes. Women denied a wanted abortion had a greater risk of living below the poverty line, and were more likely to stay with abusive partners and suffer from anxiety and loss of self-esteem in the short-term.
The 2013 study was originally published in Perspectives on Sexual and Reproductive Health, the peer-reviewed journal of the Guttmacher Institute. The Charlotte Lozier Institute, the research arm of the Susan B. Anthony List, which opposes abortion, published its take on the data in 2015. Elizabeth Ann M. Johnson, an associate scholar for the Charlotte Lozier Institute, agreed that "the stressful circumstances of unprepared pregnancy, single-motherhood, financial pressure and relationship discord are primary concerns that must be addressed for these women." However, Johnson argued, "these circumstances are not fundamentally alleviated or ameliorated by late-term abortion."