After Tiller

PBS Premiere: Sept. 1, 2014Check the broadcast schedule »



Late abortions, which are most commonly defined as any abortions performed after the 24th week of pregnancy, comprise fewer than 1.2 percent of all abortions that occur in the United States.[1] These abortions should not be confused with abortions called "partial birth abortions," as that term refers to a particular technique used in later pregnancy that was banned by the federal government in 2003. That law was upheld by the U.S. Supreme Court in 2007.

According to a 2012 Gallup poll, only about 14 percent of Americans support the legality of abortions in the third trimester, meaning that many people who consider themselves pro-choice may not support the rights of women to have late abortions.[2]

On January 22, 1973, in Roe v. Wade, the U.S. Supreme Court ruled that the states were forbidden from outlawing or regulating any aspect of abortion performed during the first trimester of pregnancy; could only enact abortion regulations reasonably related to maternal health in the second and third trimesters; and could enact abortion laws protecting the life of the fetus only in the third trimester.[3] The Supreme Court also ruled that with any restriction, including those affecting women in the third trimester, an exception had to be made to protect the life and health of the pregnant woman. Roe v. Wade stated that a woman has a right to have an abortion up until the point when the fetus becomes viable. This decision defined "viable" as being "potentially able to live outside the mother's womb, albeit with artificial aid," adding that viability is "usually placed at about seven months (28 weeks) but may occur earlier, even at 24 weeks."[4] With current medical technology, a baby born at 24 weeks of pregnancy has a 50 percent chance of surviving.[5]

In its decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Supreme Court rejected the trimester framework of Roe v. Wade, while affirming its central holding that a person has a right to have an abortion up until the point when the fetus becomes viable.[6] The regulatory framework put forth by this ruling allows the regulation of all abortions as long as those regulations do not place an "undue burden" on women.[7]

The issue of late abortion rights has become the focus of a wave of legislation that began in 2010 with Nebraska's Pain-Capable Unborn Child Protection Act, which banned abortions after 20 weeks and included only an extremely limited exception for the physical health of the pregnant woman.[8]

At present, nine additional states -- Alabama, Arkansas, Indiana, Louisiana, North Dakota, Oklahoma, Texas, Kansas and North Carolina -- have passed similar or identical legislation. Three additional states (Arizona, Georgia and Idaho) have passed comparable laws -- some with even earlier restrictions (Arizona bans abortions after 18 weeks) -- and are waiting to enact the bans pending the outcome of litigation. Since Roe v. Wade was decided, many states have significantly restricted abortions in the third trimester, which is one reason there are only four doctors in the United States who publicly acknowledge providing this care.[9] Due to efforts to restrict these abortions further, as well as efforts to limit abortions at earlier points in pregnancy, the number of states where late abortion is available is decreasing sharply.


There are about 1.2 million abortions performed in the United States each year, and of these, 88 percent occur in the first trimester of pregnancy. About 1.2 percent of these abortions occur after 21 weeks.[10] A far smaller number of abortions occur at 24 weeks or later, and it is these abortions that are the focus of After Tiller. They are provided for a small, but important patient population.

Debates over women's reproductive rights and the current legislative landscape have led to a number of popular myths about late abortions and the women who seek them. Among those myths is that women who seek late abortions are irresponsible, or make flippant or casual decisions about whether to have abortions. On the contrary, research has found that women are very thoughtful as they weigh the multitude of factors, responsibilities and realities of their lives in their decisions about abortion.[11]

Reasons for seeking late abortions fall into two major categories.

The Status of the Fetus

Sometimes a woman decides to terminate a pregnancy because testing has established that the fetus is not developing as expected. There can be several reasons for this occurring in the third trimester of pregnancy:

  1. Some fetal abnormalities only develop as the pregnancy advances (e.g., fetal stroke), some can only be detected later in the pregnancy (e.g., dwarfism) and some can worsen with time (e.g., hydrocephalus, excess water in the brain).
  2. Many women do not have access to early, comprehensive prenatal care, so abnormalities not be detected until later in their pregnancies.
  3. Often a single abnormality will prompt other developmental problems in the fetus.
  4. The decision to terminate a pregnancy because of the status of the fetus can take time, because often the pregnancy is very much wanted. Often patients seek multiple opinions, which also takes time, especially for those who have to travel for specialty care.

The Health Needs of the Pregnant Woman

A woman may have a severe medical condition that develops late in the pregnancy, or the pregnancy may develop in such a way that there is significant risk to the woman's health, and a third-trimester abortion may be needed to save the life of the woman.

A woman may decide to terminate a pregnancy because she believes it threatens her physical, emotional, mental, or family health, safety or well-being.[12] For example:

Many women do not know that they're pregnant until late in their pregnancies.

  1. Some women do not have symptoms of pregnancy, so they are never prompted to take pregnancy tests.
  2. Some women do not experience body changes suggestive of pregnancy, sometimes because of weight, height or body conditioning.
  3. Some women continue to have intermittent bleeding during their pregnancies that they interpret as periods.
  4. Some women visit healthcare providers and are told they're not pregnant.
  5. Some women have experienced non-consensual sex and thus are disassociated from the pregnancy potential.
  6. Some women use one or more forms of birth control or take the morning after pill, without realizing that these could have failed. (No form of birth control is 100 percent effective, not even sterilization.)[13]

Many women do know that they are pregnant and want abortions but are unable to react quickly. There are several possible reasons for this.

  1. Fear. This is most common among teenagers, but is seen in all age groups. A teenager who has been told that she will be kicked out of the house or that she will bring a huge amount of shame upon her family should she get pregnant has a very hard time telling her parents that she is pregnant. (In addition, many states require parental involvement for a teenager to have an abortion.)[14]
  2. Money. Abortion is more expensive the further in pregnancy a woman is. Only 17 states allow low-income women to use Medicaid to pay for abortions, so most women have to raise the money. For every week after 12 weeks the cost increases, so it is not uncommon for women to get later and later in their pregnancies as they try to raise the money they need.
  3. Access. With the states placing growing restrictions on abortion, access has become an increasingly important issue. Not only are there fewer facilities where abortions are performed, but most facilities do not offer abortions after the first trimester. A common scenario is a woman seeking care at the facility nearest her home. She is beyond the gestational limit of that facility and is referred to another location. She now has to raise additional money to pay for the procedure and for transportation, must arrange to take off more time from work and may have to find child care as well. By the time she has organized all of that and arrives at the next facility, she has passed that facility's gestational limit as well, and on and on it goes. If she's extremely persistent and resourceful she will eventually make it to one of the facilities seen in After Tiller.
  4. Change in circumstances. A woman may have initially welcomed a pregnancy, but then something in her life changes drastically -- her partner becomes abusive, or goes to jail, or leaves her, or a hurricane destroys her home -- and she reassesses, realizing that she cannot do a good job of parenting this baby if she has it.
  5. Chaotic life situation. Some third-trimester abortion patients live lives of chaos that most people cannot even imagine -- lives of extreme poverty, physical and emotional abuse and social isolation. Ultimately a woman in this situation will often come to realize that bringing a baby (or another baby) into her life would likely give that child a lifetime of hardship and suffering, and that is something she does not want to do.

What About Adoption?

The question of adoption is commonly raised in discussions about third-trimester abortion.[15] Many people can have difficulty understanding why patients choose to have abortions, rather than carrying their pregnancies fully to term and then choosing adoption for the children. Adoption, like abortion, is a complicated and difficult decision.[16] Data shows that when adoption is voluntarily selected women and children do well, but when it is involuntarily imposed there can be significant long-term repercussions.[17]

Here are some examples from Dr. Shelley Sella of why a woman might decide that adoption is not the right decision for her:

  1. A woman may believe that the child she is carrying would not be healthy given her own medical history or the behaviors she engaged in during pregnancy.
  2. A woman may be concerned that the child will be mistreated.
  3. Women do not want their children to feel that they were abandoned. The doctors in After Tiller say that they hear this frequently from women who were adopted themselves.
  4. Some women whose pregnancies were especially traumatic do not want to have to tell those experiences to the children. Some women worry that even if they choose adoption, their children will look for them when they are older.
  5. It is physically safer for a woman to have a third-trimester abortion than it is for her to have a full-term delivery.[18] Protecting health for a future pregnancy is a significant concern for some pregnant women.

Whatever the specific circumstances, the decision to have a third-trimester abortion is always complicated, serious and deeply personal.


As part of the 1973 Roe v. Wade U.S. Supreme Court decision, the court ruled that state laws prohibiting abortion are unconstitutional on the grounds that they violate a woman's "right to privacy." The court argued that the First, Fourth, Ninth and Fourteenth Amendments protect an individual's "zone of privacy," which the court considered "broad enough to encompass a woman's decision whether or not to terminate her pregnancy."[19] However, the court also determinedthat a woman's right to an abortion is not absolute and that states may restrict or ban abortions after fetal viability under certain conditions.

As of September 1, 2013:[20]

  • 19 states prohibit abortions starting at fetal viability (with exception for the life and health of the woman)
  • two states prohibit abortions starting at fetal viability (with exception for only the life of the woman)
  • eight states prohibit abortions beginning at 20 weeks

While nine states permit third-trimester abortions without restriction, there are only three states with known providers: Maryland, Colorado and New Mexico.


Today in the United States, only four doctors openly acknowledge that they perform abortions at 25 weeks or later. Why?

1. Legislative Restrictions

Most states limit abortions in the third trimester to those necessary to save a woman's life. A few more states will allow abortions if the health of the fetus is so compromised that it is likely to die when it is born. However, only nine states allow third-trimester abortions for the many reasons women seek them (see earlier discussion).

2. Violence

Physical intimidation of abortion care facilities and providers is common. In 2000, 82 percent of large providers (facilities providing 400 or more abortions per year) experienced some type of harassment. Typically, harassment took the form of picketing and physical contact with or blocking of patients, but 15 percent of large providers reported that they had also received at least one bomb threat.[21]

The death of Dr. George Tiller in 2009 is a tragic example of the profound threat to individuals who provide abortion care. In fact, eight abortion care workers have been murdered since 1977, with an additional 17 murders attempted. The film gives us a glimpse into the issues of security and safety that these doctors face. Dr. Robinson tells us about having a safety inspection of her home by a federal marshal. Dr. Hern had gunshots fired into his office, and his mother frequently receives threatening phone calls. And all of the doctors have received death threats and hate mail over the years that they have been doing this work.

3. Lack of Training in Abortion Care at Medical Schools and in Residency Programs

In the film, Dr. Susan Robinson comments, "I just thought the other day, I can't retire. My God. There aren't enough of us."

The reasons for the lack of new physicians to take the place of these four doctors are numerous. Many medical schools do not include abortion in their curricula. While there is a requirement that obstetrics and gynecology residency programs include abortion training, the U.S. Congress prohibits penalizing any program that chooses not to teach this procedure.[22] Consequently, almost half of all obstetrics and gynecology residency programs do not offer any abortion training. Even when training is obtained, most graduating residents find institutional barriers to incorporating abortion care into their practices. To get jobs, many doctors have to sign contracts pledging not to perform abortions.[23]

So why, then, do the doctors in the film perform this procedure? The doctors give us several reasons. Dr. Hern shares the tragedy he witnessed as a younger physician when he cared for babies who were abused, battered and damaged "because their parents didn't want them," noting the stark contrast between the women under his care who were prepared to have children and those who weren't. He also speaks about his experience working as a Peace Corps physician in Brazil, where he says many women died after receiving illegal abortions. Dr. Carhart fears the harm women will do to themselves or to their babies if they are unable to access such services legally and safely. Dr. Sella reports that she was drawn to abortion care because of the elements it shares with her previous work in midwifery, such as an emphasis on emotional support for the patients, and on treating the woman as the best judge of her own reproductive decision-making process. And Dr. Robinson, who initially decided to provide abortions because she thought that a wave of recent anti-abortion violence might dissuade many doctors from continuing to provide that care, finds the gratitude of her patients incredibly rewarding.


A number of groups and individuals oppose the practice and legality of abortion for a range of reasons, including ethical, religious and political reasons. According to a 2012 Gallup poll, 61 percent of Americans support legal abortion in the first three months of pregnancy, while only 14 percent believe abortion should be legal in the last three months of pregnancy.[24] The issues raised by those who oppose abortion include the point at which human life begins, viability of the fetus outside the womb, the point at which a fetus can feel pain, health risks to the mother during abortion procedures, religious beliefs, opposition to abortions that are considered elective (i.e., not for the sake of the physical health of the mother or child) and support of alternatives to abortion, such as adoption.[25]

Major organizations and leaders in the anti-abortion movement include the groups Operation Rescue and National Right to Life. Religious groups such as the Catholic church, political groups and individuals are also involved. Efforts to end abortion practices range from peaceful sit-ins and advocacy, to work developing alternative support programs for mothers with unwanted pregnancies, to petitions and campaigns to pass legislation banning abortion, to actions to close clinics and extreme cases of property damage and violence.[26]

In 1994, the Freedom of Access to Clinic Entrances Act was passed, making it a federal offense to impede an individual's access to a clinic through injury, intimidation or interference.[27] Some states, such as Massachusetts, also enacted "buffer zone" laws, which require protesters to stay at least 35 feet away from abortion clinics. However, in 2014, the U.S. Supreme Court ruled in McCullen v. Coakley that the "buffer zone" law in Massachusetts infringes on anti-abortion protesters' First Amendment rights to free speech and to assemble peaceably. The court encouraged states to focus instead on protecting staff and patients through laws concerning harassment, intimidation and obstruction.[28]

[1] Centers for Disease Control and Prevention. "Abortion Surveillance -- United States, 2010."

[2] Gallup. "Majority of Americans Still Support Roe v. Wade Decision."

[3] Legal Information Institute. "Roe v. Wade."

[4] Rees III, Grover. "State Protection of the Viable Unborn Child After Roe v. Wade: How Little, How Late?" Louisiana Law Review 37, No. 1 (1976).

[5] Advancing New Standards in Reproductive Health. "The Science of 'Viability'."

[6] Frontline. "Roe v. Wade and Beyond."

[7] Legal Information Institute. "Planned Parenthood of Southeastern Pennsylvania v. Casey (1992)."

[8] U.S. Congress. "H.R.1797: Pain-Capable Unborn Child Protection Act."
Legislative Bill 1103

[9] Guttmacher Institute. "An Overview of Abortion Laws."

[10] Guttmacher Institute. "Induced Abortion in the United States."

[11] Foster D.G. et al. "Attitudes and Decision Making Among Women Seeking Abortions at One U.S. Clinic." Perspectives on Sexual and Reproductive Health 44, No. 2 (June 2012).

[12] Finer, Lawrence B. et al. "Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives." Perspectives on Sexual and Reproductive Health 37, No. 3 (September 2005).

[13] Centers for Disease Control and Prevention. "Contraception."

[14] American Civil Liberties Union. "Laws Restricting Teenagers' Access to Abortion."

[15] Dominus, Susan. "Campaigning for Common Ground in Abortion Debate." The New York Times, June 18, 2010.

[16] Biggs, M.A. et al. "Understanding Why Women Seek Abortions in the U.S." BMC Women's Health 13, No. 29 (July 5, 2013).

[17] Fessler, Ann. The Girls Who Went Away: The Hidden History of Women Who Surrendered Children for Adoption in the Decades Before Roe v. Wade. New York: Penguin, 2006.

[18] Gordon, Serena. "Abortion Safer for Women Than Childbirth, Study Claims. U.S. News & World Report, January 23, 2012.

[19] PBS. "Roe v. Wade (1973)."

[20] Guttmacher Institute. "An Overview of Abortion Laws."

[21] Finer, Lawrence B. et al. "Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives." Perspectives on Sexual and Reproductive Health 37, No. 3 (September 2005).

[22] Rogers, Beth. "Secret Practice." The New Physician, November 2009.

[23] Freedman, Lori. Willing and Unable: Doctors' Constraints in Abortion Care. Nashville: Vanderbilt University Press, 2010.

[24] Gallup. "Majority of Americans Still Support Roe v. Wade Decision."

[25] Gale Global Issues in Context. "Abortion.";jsessionid=7350E1938A37F3252FD3A596774E7584

[26] Stumpe, Joe and Monica Davey. "Abortion Doctor Shot to Death in Kansas Church." The New York Times, May 31, 2009.

[27] The Federal Bureau of Investigation. "Freedom of Access to Clinic Entrances."

[28] Liptak, Adam and John Schwartz. "Court Rejects Zone to Buffer Abortion Clinic." The New York Times, June 26, 2014.