The ability to obtain abortion care without delay is critically important to women’s reproductive health. Abortion is a safe and legal medical procedure, and waiting periods are medically unnecessary. They introduce an unnecessary hurdle to obtaining medical care and intrude on the patient-provider relationship, while failing to protect the best interests of the patient. However, many states require women to wait for some period of time—from 18 hours to three days or more—between preabortion counseling and the abortion itself. Some states require in-person counseling (rather than counseling via phone, internet or mail) before the waiting period can begin. These types of provisions mean that women must make two trips to a health care provider in order to obtain an abortion. Making two trips can pose a burden for women who need to arrange for time off from work or caretaking duties, and for those who live far from an abortion provider. The need to gather funds or make travel arrangements may lead women to have later abortions, which are more expensive and can pose a higher risk.
STATE LAWS AND POLICIES
For a chart of current laws and policies in each state related to waiting periods for abortion, see Counseling and Waiting Periods for Abortion.
For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.
RELEVANT DATA AND ANALYSIS
Lack of Medical Need for Waiting Periods
Waiting periods are not medically necessary and conflict with the principles of medical ethics.
- Waiting periods serve no medical purpose; these hurdles are intended to make abortion less accessible.1,2
- Like all health care providers, abortion providers operate under the principles of medical ethics and are required to obtain informed consent before an abortion procedure.3 Informed consent counseling should not aim to hinder or discourage patients from receiving care, but rather ensure that patients have the relevant and accurate information needed to make health care decisions.4
- Waiting periods are almost never required for other medical procedures.* Imposing them on women seeking abortion is an unnecessary burden and singles out these patients as unable to make informed decisions without the imposition of a state-mandated waiting period.1
Women Sure About Abortion Decision
Women are confident in their decision to have an abortion. Mandated waiting periods only add a delay between a woman’s decision and her procedure.
- A study of Wisconsin’s 2013 mandatory preabortion ultrasound law found that 93% of women were certain in their decision to obtain an abortion, both before and after the law was implemented.5
- A nationally representative survey of abortion patients conducted in 2008 found that 92% of women reported they had made up their mind to have an abortion prior to making an appointment.6
- According to a study of women seeking abortion at a U.S. clinic in 2008, 99% of abortion patients reported being “sure” or “kind of sure” of their decision to have an abortion, and 98% reported that “abortion is a better choice for me at this time than having a baby.”7
- A 2015 qualitative study on travel-related barriers to abortion found that facing multiple barriers, such as limited access to clinics and financial constraints, had a cumulative impact on abortion access.8 The study authors considered waiting periods to be harmful in the context of these barriers.
- In a 2014 study of Utah women seeking an abortion, 74% of participants said that the 72-hour waiting period did not affect the certainty of their decision to have an abortion and 17% said that the waiting period made them more certain about the decision.9
- Waiting periods can be detrimental to women’s mental health. In 2011, Texas implemented a law requiring an ultrasound, followed by a 24-hour waiting period.10 Among surveyed patients seeking abortion care after these restrictions went into effect, almost one-third reported that the waiting period had a negative effect on their emotional well-being.
Delays Due to Waiting Periods
Waiting periods can contribute to delays in obtaining abortion care, which is problematic because both the cost and risk of an abortion increase as the pregnancy continues.
- An expert panel convened by the National Academies of Sciences, Engineering and Medicine in 2018 found that requiring a waiting period before receiving an abortion may increase both the risk of complications for the patient and cost of the procedure, with no evidence that waiting periods improve abortion safety.11
- In a 2014 nationwide survey of abortion patients, two circumstances were associated with a longer time to appointment and making the appointment more than two weeks before the procedure: exposure to disruptive life events and living in a state with a waiting period.12
- Three studies conducted in Mississippi in the early 1990s found that the state’s mandatory in-person counseling and 24-hour waiting period were associated with a decline in the abortion rate, a rise in abortions obtained out of state and an increase in the proportion of second-trimester abortions.1,13–15
- Later abortion procedures are typically more costly than procedures performed at earlier gestational ages. For instance, in 2011 and 2012, the median charge for a surgical abortion was $495 at 10 weeks’ gestation, compared with $1,350 at 20 weeks.16
- More than half (58%) of abortion patients in a 2008 study wished they could have gotten an abortion earlier in pregnancy.17 Three in five attributed the delay they experienced to the time it took to make arrangements and raise money.
- The risk of complications from abortion—although exceedingly small at any point—increases with gestational age.18,19
- The number of maternal deaths associated with abortion increases with the length of pregnancy, from 0.3 for every 100,000 abortions at or before eight weeks to 6.7 per 100,000 at 18 weeks or later.18
- Even when state laws do not ban later abortion services, the number of available abortion providers tends to decrease as pregnancy progresses.16
- Poor women seeking abortion are often caught in a vicious cycle: Costs may cause delays in obtaining care, while delays push costs even higher, while increasing the health risks of the procedure.20
Unnecessary Clinic Trips
Some states have in-person counseling requirements, which means that if a waiting period is also in effect, a woman seeking an abortion must make two trips to her provider. Women who have to make two trips may face more complicated logistics, additional costs and delays in care.
- Because of laws that impose an additional, medically unnecessary trip to an abortion clinic, women may encounter logistical challenges and costs related to child care, taking time off work, travel and lodging (if the clinic is not close to home).1 Such costs may act as barriers to care for low-income women, a group that experiences particularly high unintended pregnancy rates.21
- The added complications of logistics and cost can lead to a delay in obtaining abortion care. Three in five abortion patients surveyed in 2004 who experienced a delay in obtaining an abortion reported that the time it took to make arrangements and raise money contributed to the delay.17
- A recent study of Utah’s in-person counseling law found that a 72-hour waiting period translated, on average, into eight days between counseling and procedure for those patients who obtained an abortion.22 In addition, the in-person counseling requirement forced 6% of patients to disclose that they were seeking an abortion to people who had not known, including employers, child care providers and family members.
RECENT STATE ACTION ON THIS ISSUE
States that have addressed this issue over the past three years are listed below.
E: State enacted a relevant measure
V: State vetoed measure
A: State adopted measure in at least one chamber
States that require women to wait a specified amount of time between counseling and abortion procedure
States that require counseling to be provided in person
*An exception is Medicaid-funded female contraceptive sterilization, which cannot be performed until at least 30 days after informed consent is obtained.
1. Joyce TJ et al., The Impact of State Mandatory Counseling and Waiting Period Laws on Abortion: A Literature Review, New York: Guttmacher Institute, 2009, https://www.guttmacher.org/report/impact-state-mandatory-counseling-and-waiting-period-laws-abortion-literature-review.
2. Boonstra HD and Nash E, A surge of state abortion restrictions puts providers—and the women they serve—in the crosshairs, Guttmacher Policy Review, 2014, 17(1):9–15, https://www.guttmacher.org/gpr/2014/03/surge-state-abortion-restrictions-puts-providers-and-women-they-serve-crosshairs.
3. National Abortion Federation, Ethical Principles for Abortion Care, 2011, http://prochoice.org/wp-content/uploads/NAF_Ethical-_Principles.pdf.
4. American College of Obstetricians and Gynecologists (ACOG), Informed consent, ACOG Committee Opinion No. 439, Obstetrics & Gynecology, 2009, 114(2):401–408, http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Informed-Consent.
5. Upadhyay UD et al., Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: a mixed methods study, PLoS ONE, 2017, 12(7): e0178871.
6. Moore A, Frohwirth L and Blades N, What women want from abortion counseling in the United States: a qualitative study of abortion patients in 2008, Social Work in Health Care, 2011, 50(6):424–442.
7. Foster DG et al., Attitudes and decision making among women seeking abortions at one U.S. clinic, Perspectives on Sexual and Reproductive Health, 2012, 44(2):117–124.
8. Jerman J et al., Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states, Perspectives on Sexual and Reproductive Health, 2017, 49(2):95–102, https://www.guttmacher.org/journals/psrh/2017/04/barriers-abortion-care-and-their-consequences-patients-traveling-services.
9. Roberts SCM et al., Do 72-hour waiting periods and two-visit requirements for abortion affect women’s certainty? A prospective cohort study, Women’s Health Issues, 2017, 27(4):400–406.
10. Texas Policy Evaluation Project, Impact of abortion restrictions in Texas, 2013, http://www.utexas.edu/cola/txpep/_files/pdf/TxPEP-ResearchBrief-ImpactofAbortionRestrictions.pdf.
11. National Academies of Sciences, Engineering and Medicine, The Safety and Quality of Abortion Care in the United States, Washington, DC: National Academies Press, 2018.
12. Jones RK and Jerman J, Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/delays-in-accessing-care-among-us-abortion-patients.
13. Althaus FA and Henshaw SK, The effects of mandatory delay laws on abortion patients and providers, Family Planning Perspectives, 1994, 26(5):228–231 & 233.
14. Joyce T, Henshaw SK and Skatrud JD, The impact of Mississippi’s mandatory delay law on abortions and births, Journal of the American Medical Association, 1997, 278(8):653–658.
15. Joyce T and Kaestner R, The impact of Mississippi’s mandatory delay law on the timing of abortion, Family Planning Perspectives, 2000, 32(1):4–13.
16. Jerman J and Jones RK, Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment, Women’s Health Issues, 2014, 24(4):e419–424, https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.whi.2014.05.002.pdf.
17. Finer LB et al., Timing of steps and reasons for delays in obtaining abortions in the United States, Contraception, 2006, 74(4):334–344.
18. Zane S et al., Abortion-related mortality in the United States: 1998–2010, Obstetrics & Gynecology, 2015, 126(2):258–265.
19. Upadhyay UD et al., Incidence of emergency department visits and complications after abortion, Obstetrics & Gynecology, 2015, 125(1):175–183.
20. Boonstra HD, Abortion in the lives of women struggling financially: why insurance coverage matters, Guttmacher Policy Review, 2016, 19:46–52, https://www.guttmacher.org/gpr/2016/07/abortion-lives-women-struggling-financially-why-insurance-coverage-matters.
21. Guttmacher Institute, Unintended pregnancy in the United States, Fact Sheet, 2016, http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html.
22. Roberts SCM et al., Utah’s 72-hour waiting period for abortion: experiences among a clinic-based sample of women, Perspectives on Sexual and Reproductive Health, 2016, 48(4):179–187.