Republicans scrambling to address mounting backlash to abortion bans have landed on what they hope they can market as a moderate political compromise: limiting abortion after 12 weeks of pregnancy.
Over the last month, Republicans in North Carolina and Nebraska have passed 12-week abortion bans, a dramatic reduction in access for states that previously allowed abortion up until 20 weeks and 22 weeks, respectively.
North Carolina’s ban would permit abortion for rape victims through 20 weeks, for life-threatening fetal anomalies through 24 weeks, and to protect the life of the mother throughout. Nebraska’s new ban would permit exceptions for rape and to save the life of the mother, but not for fatal fetal anomalies. (Health of pregnant person exceptions have been notoriously confusing for doctors in practice, who fear criminal sanctions for violating the vague statutes.)
Republican politicians are casting these new 12-week bans as “mainstream,” comparing them to even more extreme GOP-led states that have banned virtually all abortion, and pointing to other countries, particularly in Europe, that also impose gestational age limits at 12 weeks.
The rhetorical strategy of invoking other countries to justify banning abortion will sound familiar to those who followed the overturn of Roe v. Wade. In that case, Dobbs v. Jackson, Mississippi lawmakers defended their 15-week abortion ban by pointing out that most European countries have even earlier restrictions.
In the Dobbs Supreme Court hearing itself, Justice John G. Roberts claimed the proposed 15-week ban mirrors “the standard that the vast majority of other countries have.” In his majority opinion, Justice Samuel Alito cited a study published by a leading anti-abortion group that argued the US was out of step with the rest of the world in terms of abortion after 20 weeks.
The study, published by the think tank arm of the Susan B. Anthony Pro-Life America, said 47 out of 50 European nations limit “elective” abortion before 15 weeks, meaning before then doctors are not required to attest to a particular justification for the abortion.
But differences between the US and European countries are more complex than that simple comparison suggests. In practice, abortion limits in the United States are far more restrictive than what exists in most of the Western world, including in nations with gestational age limits at 12 weeks, like Germany, Denmark, Belgium, and Italy.
This distinction between “elective” abortions (or “abortion on demand,” as it’s more provocatively called) and “therapeutic” abortions, which are done for medical reasons, might seem like a key distinction between the US and Europe. But in practice, the line is much blurrier. All abortions are ultimately elective — no one is forced to end a pregnancy, even if a doctor recommends it. Plenty of elective abortions are done for therapeutic reasons.
Moreover, European countries that have 12-week limits on “elective” abortions still make it fairly easy for women to get abortions later on, with relatively broad exceptions for mental health or socioeconomic circumstances. Republicans have aggressively fought against similar exceptions, and in particular have worked to bar consideration of mental health risk — even the risk of suicide if a pregnancy continues — as a factor.
And in other ways, European countries make it easier to get an abortion than in even relatively permissive jurisdictions in the United States. Across Europe, abortion services are covered under national health insurance, meaning the cost of accessing care is a far lower barrier for pregnant people facing time constraints.
By contrast, in the US, cost is one of the biggest hurdles to ending a pregnancy. Even though more than 90 percent of abortions occur within the first 13 weeks, roughly 75 percent of all US abortion patients are low-income according to 2014 numbers, and researchers find Americans needing care in the second trimester tend to be those with less education, Black women, and women who have experienced “multiple disruptive events” in the past year, such as losing a job.
Republican lawmakers are also bucking international trends in working to aggressively restrict access to telehealth abortion care and medication abortion generally — which allows patients, especially those who live in remote and rural areas, to get the abortion services they seek on a faster timeline. Both North Carolina and Nebraska have fully banned abortion via telehealth, despite research affirming its safety and efficacy.
Across the globe, the clear trend has been to expand access to abortion, decriminalize the procedure, and loosen restrictions. While restrictive policies, including earlier gestational limits, still present barriers for international abortion care, per the Center for Reproductive Rights, nearly 60 countries have liberalized their laws and policies on abortion since 1994. Only four — the US, El Salvador, Nicaragua, and Poland — have further restricted rights.
Even with earlier gestational limits, abortion in Europe is broadly affordable and accessible. This is not the paradigm Republicans are proposing in the United States. They are fighting to keep abortion expensive, particularly for low-income patients who rely on Medicaid; to limit the reasons like mental health for which patients can access legal abortion; and to restrict access to care, all while imposing bans on telemedicine, ramping up criminal penalties for providers, and shortening the legal timeline for pregnant people to raise funds, arrange travel, and book mandatory medical appointments.
Understanding international abortion access in practice
Republicans have been eager to point to countries that restrict “elective” abortion after 12 weeks to justify the supposedly mainstream nature of their new bans. But across Europe, the cost of abortion care is fully paid for by federal governments, making first-trimester abortions simply easier to do. Abortions in the US can easily exceed $500 out of pocket, and only 17 states currently cover abortion under their Medicaid programs, which they must do with state funds, not federal dollars, as Congress prohibits it.
Another difference is that abortion exceptions for “health of the pregnant woman” in Europe take into account mental health, too. In Germany, for example, while abortion is permitted upon request throughout the first 12 weeks, someone can seek legal abortion through 22 weeks if it would help them “avert the danger of grave impairment to [their] physical or mental health.”
In Britain, which allows legal abortion up to 24 weeks, it’s similarly clarified that a pregnant person can access care if it’s determined that ending the pregnancy would cause less damage to the patient’s physical or mental health than continuing to carry.
“This is always granted [by doctors] under the correct assumption that continuing a pregnancy is always more dangerous than terminating, and that continuing an unwanted pregnancy is always detrimental to a person’s mental health,” said Maria Lewandowska, a reproductive and sexual health researcher at London School of Hygiene and Tropical Medicine.
Any doctor can provide this authorization, she said, and in practice, patients often get approval directly from doctors at abortion clinics. Advocates in the UK have been encouraging the government to authorize nurses and midwives to grant this permission, too.
Some countries don’t explicitly state “mental health” in their statute, but recognize that maternal health includes psychological health. The author of France’s 1975 abortion law clarified during legislative hearings that “the very term ‘health’ covers, it seems to me, the mental aspect as well as the physical aspect.” The World Health Organization’s definition of “health” includes “mental health.” In Canada, leaders make no formal distinction between physical and mental health, which Joyce Arthur, executive director of the Abortion Rights Coalition of Canada, says allows providers to “better integrate abortion care into the broader health care system.”
Meanwhile, research on the psychological harm associated with carrying unwanted pregnancies continues to mount. The Turnaway Study, a longitudinal study on the effects of unwanted pregnancy on patients’ lives, found that the mental health of women able to end unwanted pregnancies was significantly better than that of women forced to carry to term. Another report published in 2022 found that suicide is a leading cause of death for pregnant people during pregnancy and the first year following it.
Anti-abortion activists in the US, for their part, continue to dismiss these studies. “Having an abortion will not mitigate mental health issues,” said Laura Echevarria, a spokesperson for the National Right to Life Committee, which has lobbied state legislatures to exclude mental health.
In addition to providing exceptions for mental health and paying for abortion care, pregnant people in European countries can also seek legal abortion beyond their country’s 12- or 14-week limit for broad socioeconomic reasons, like feeling too young or too old to have children, feeling consumed by existing children, being a single parent, or lacking a stable housing or financial situation. The Center for Reproductive Rights counts at least 16 European countries that permit abortion on socioeconomic grounds.
In Denmark, for example, though the country has a 12-week ban on paper, it’s considered relatively feasible for residents to get approval for abortion beyond that. In 2021, 803 pregnant people applied to get an abortion in Denmark beyond 12 weeks, and 750 were approved.
Thousands of pregnant women living in countries with 12-week abortion bans travel internationally to end their pregnancies
Even with broader grounds for legal exceptions and greater financial assistance available in countries with earlier gestational age limits, first-trimester bans in Europe still force thousands of pregnant people to travel internationally every year to end their unwanted pregnancies. (A French parliamentary report from 2020 estimated that as many as 4,000 French women traveled abroad for abortion annually due to gestational limits. In 2022, French legislators extended their limit to 14 weeks.)
One study published in March looked at people who traveled from countries like Austria, Bulgaria, France, Germany, and Italy to the Netherlands or England for later abortion care. Over half of the pregnant people surveyed hadn’t learned they were even pregnant until they were at least 14 weeks along, when they had already surpassed the limits in their home countries.
The reasons participants cited for not knowing they were pregnant hold strong relevance for pregnant people in the US living in states with new 12- or six-week bans. The participants all said they would have preferred earlier abortion care but didn’t know they were pregnant due to reasons like irregular periods, lack of clear pregnancy signs, misinformation by doctors about contraception, or their gestational age.
While European passports make travel to other EU countries relatively easy, pregnant people then have to shoulder the cost of travel and the abortion, as national governments only fund abortion care for their own residents. Feminist activists help fundraise for pan-European surgical abortion, as well as the distribution of medication abortion to regions where it’s illegal, but second-trimester abortions for non-Dutch residents can cost up to 1,100 euros. Abortion travel also delays care, which increases a pregnant person’s health risks.
Twelve-week bans in the US won’t end the need for abortion care in the second trimester, because there will always be women who lack the knowledge that they’re pregnant before then. But if Republicans wanted to reduce the need for abortion after 12 weeks, they could back straightforward policies to make the procedure more accessible and affordable.