Pre-abortion ultrasound: the medical evidence and why it’s important

The growing momentum among state legislators to enact ultrasound “requirements” for abortion is an interesting tactic. Currently 20 states regulate the provision of ultrasound by abortion providers. The point appears to be twofold:

  • raise the cost of the procedure to reduce the number of women who can afford an abortion
  • require/offer/describe a view of the fetus to dissuade/shame pregnant women into not having the procedure

It’s interesting to me that on both sides there has been very little discussion of the medical evidence. So that’s what I’m going to do.

Issue #1: Cost

Second-trimester abortion

Let’s just take that off the table. Every second trimester abortion needs an ultrasound and often gets more than one. Second-trimester abortions are more often done for birth defects, typically diagnosed or confirmed by ultrasound (sometimes a few ultrasounds are done). In addition, these procedures require more skill the further along, so it is essential the practitioner knows the gestational age with as much accuracy as possible. Ultrasound laws will not change any procedure costs for 2nd trimester ultrasounds, but they may affect the viewing requirements (whether the woman sees/hears a description of the ultrasound). I’ll get to that in just a bit.

First-trimester abortion

Many providers already do a 1rst trimester ultrasound, especially with medical abortion. This is because a medical abortion can only be done up to 63 days (9 weeks). However, there is a growing body of literature suggesting medical abortion can safety be accomplished without an ultrasound for 98% of women. So these laws will prevent practitioners from doing away with an ultrasound (i.e. prevent them from practicing evidence based medicine) which will halt efforts to expand medical abortion into low resource settings. Ultrasound requirements will also affect many women getting a surgical procedure as and ultrasound is typically not required if the size of the uterus agrees with the dating of the pregnancy (although some providers do ultrasounds anyway, generally for medico-legal reasons).

So regarding cost, ultrasound requirements may affect a lot of women seeking a 1rst trimester abortion.

Does this accomplish anything? (Which you might want to know if you are going to spend tax payer money enacting a law). No. In fact, studies tell us that both cost and local availability of a provider has no effect on the decision to get an abortion, it simply delays the procedure while the woman figures out her resources. It is insulting to insinuate that a woman has an abortion out of convenience or cost. In Canada, where abortion is free and unencumbered by ill-informed politicians, the rate of abortion is lower than in the United States. It is sex education and widespread access to medical care and contraception that reduces abortion, not laws.

Issue #2: Viewing the image to dissuade a woman from having an abortion

A 2009 study looked at whether viewing an ultrasound image pre-abortion was something women wanted and whether it had an impact on her choice to have the procedure or her emotional experience(1). When given the option, almost 73% of women chose to view their ultrasound image and of those who did, 85% felt it was a positive experience. Not one woman changed her mind about having the abortion after viewing the image. Ten women were selected for an in-depth interview on the subject and all felt that women should be given the choice about viewing their image.

So in fact, states that require a provider to offer a view of the image to the patient are following evidence-based recommendations. Requiring a patient view the image, such as in Texas, is another matter.

We know that cost and laws do not affect the abortion rate. We also know that long acting reversible contraception lowers the abortion rate. There are some excellent studies that tell us that when women get depo-provera or an IUD post-abortion they are far less likely to have a subsequent unplanned pregnancy. But interestingly, many in the anti-choice movement also discourage birth control. If they were really pro-life (i.e. wanting to prevent every abortion possible) they would be handing out contraceptives instead of picketing clinics and clamoring for laws that restrict tobacco, as cigarettes are responsible for the deaths of 5-7% of all premature babies and cause 23-31% of SIDS).

Laws that increase barriers to abortion create hardships for the women seeking the procedure but they do nothing to lower the abortion rate. To focus on abortion restrictions and not contraception is the height of hypocrisy and a waste of taxpayer dollars, because the laws will inevitably get challenged and held up in court, as we have seen in South Carolina and Oklahoma.

Sigh. (See my recent piece, What if all the money spent fighting about abortion…).

There is no medical evidence to support ultrasound laws. They are a waste of taxpayer dollars and do nothing to accomplish the goal of reducing abortion. They also create a dangerous precedent of allowing hypocritical politicians to set unacceptably low standards of medical care based on political goals, religion, and misogyny.

Smaller government indeed.

1) Kulier R, Kapp N. Comprehensive analysis of the use of pre-procedure ultrasound for first- and second-trimester abortion. Contraception 2011;83:30-33.

Join the Conversation


  1. Thank you for this post – I will be sharing it!! So great to actually hear a Dr and not a politician speak on these issues.

    1. I had a first trimester abortion and insisted on seeing the ultrasound. I wanted to be aware of what I was doing,preventing a life.I was also very aware that had I continued the pregnancy, I would not be altruistic and choose adoption.I would have been a very poor parent. As a foster parent now, I know and see the damage that is done to children by( politely), unready parents

      1. Yes, the damage that can be done to the child of unready parents is real and real big. But, IMHO aborting the fetus isn’t the answer. Teaching the would-be (albeit unready) parents how to prevent a pregnancy IN THE FIRST PLACE is the better option.. Teach girls to keep their legs together and the guys to use condoms (as much as that sounds crass) is the more responsible plan. If young people are TAUGHT that there’s always an ‘out,’ people will NEVER take responsibility for their actions and the cycle is likely to continue with THEIR children.

      2. Why do you say that girls should keep their legs together and guys should use condoms? Why don’t you say the guys should keep their pants on as well? It’s interesting that you say girls shouldn’t have sex full stop, but allow the boys to have (protected) sex.

      3. My grandmother seriously considered aborting my mother. My grandmother was extremely abusive and did a lot of damage to my Mom. Guess what, my Mom was still glad to be alive and I am too. I would not be here had she made the choice to destroy my mother’s life in her womb. Please, your logic is so poor.

  2. There’s really no discussion here. A woman should get an abortion however and whenever she wants. Period. No one has any say about it nor can they place any roadblocks against it.

    This isn’t philosophy where we’re trying to find truth or the meaning of life. This is black and white.

    There’s no discussion to be had. It’s the woman’s body and as sovereign over her own body and no one else has claim to it.

    1. This issue of abortion is not black and white. It’s a rights issue and it falls squarely into the realm of metaphysics and is augmented by our findings in science. The concept of ‘an unborn child’ is not a nonsensical term. There is a point when the thing developing into the uterus becomes a rights bearing entity. It is important to determine that point as best we can, because then the issue switches from a women’s right to control her own body to arbitrating the conflict between her right to control her body and the unborn child’s right to life.

      1. Except that for every person, the point where the thing developing in the uterus becomes a rights bearing identity is different. No one can “determine” that point scientifically, because “entity” isn’t a scientific term. Some people say the zygote is a human from the moment of conception, others say from birth, and others say from when it can react to stimuli.

        And even then. If something is relying on another’s body for life, and that person does something to their body and ends the life, they still should have the right to do so because they should be allowed to do whatever the hell they want with their own body.

      2. Do you want to live in a world where your government can legally require you to donate blood, plasma, a kidney or a liver to any other human that needs it to live?
        Even if you believe life begins at conception, even if you see the personal choice to have an abortion, or not, as a morally loaded one, EVEN THEN, there are logical reason to treat the legal questions of whether your living body is communal property or your own as black and white.

        As far as the ultrasound issue- I’m not sure if there’s a practical distinction between “all women are required to have ultrasounds” and “all women who cannot verify their date of conception with 100% certainty will have ultrasounds for ‘medico-legal’ reasons”. Particularly when nobody trusts women, and so many are given ultrasounds irrespective of what they say about date of conception. I’m disgusted by Virginia, but I’m pretty disgusted by the state of abortion access broadly.

        “So let me get this straight…a women views the living baby on an ultrasound and has NO difference in choosing an option other than abortion. That’s riduculous to even print. I cannot believe for a minute that seeing your own child on an ultrasound wouldn’t influence your decision to abort or not. I think the doctor is woking on opinion and not fact.”
        Have you ever had a first trimester ultrasound? They can be smudgy to the point of not being able to distinguish any features. Like, not even head-from-body. They are also imaging “living babies” that are 3-4 inches long, 1 ounce (at most). They just aren’t terribly impressive.

    2. No one has the kind of right over their own body. If you try to kill yourself you’ll be stopped by the medical profession and law enforcement, not to mention anyone else that cares about you (if you are lucky). If you put enough drugs into your body you will be hauled off to a rehab or detox. If you stab yourself you’ll be court-ordered to receive psychological help. Your argument does not fly. Plus you are talking about the body of someone else. Please read what Gianna Jessen and Abby Johnson have to say about this subject. Afterall, you are one of the lucky ones, who has made it out of the womb alive.

    3. You also failed to see that the fetus has it’s own body, it’s own DNA seperate from it’s mother. And while mothers do have some claim to their children, she is not all sovereign over her child..

  3. Again you have hit the nail on the head. Thanks for the informative piece, I have passed it along to a number of women. I am all about a woman’t right to choose. The fact that men, who are virtually clueless about what women need or want are making these laws is repugnant. I’m a man but if I was a politician I’d differ to women in medicine to write the laws on this subject. I am also 100% in favor of smaller government and the separation of church and state.

  4. Dr. Jen,

    You say there is no medical evidence to support ultrasound laws. Aren’t these procedures used to determine position (Breech) or the status of the cord?

    1. I’m not the author so perhaps she will add something else, but I don’t believe she is saying there is no medical based evidence to support ultrasound use, just ultrasound laws as they apply to abortion. Fetal position and cord placement have no bearing in the abortion setting; they don’t come into play until much later in the pregnancy. Hope this helps.

      1. “Fetal position and cord placement have no bearing in the abortion setting; they don’t come into play until much later in the pregnancy. Hope this helps.”

        I’m a nurse so please don’t talk to me about medical issues like I haven’t a clue. No, my specialty is not ob/gyn, but this is an issue that SHOULD come into play at ALL times during a pregnancy and considered abortion. The goal in this ‘exercise’ is to have fewer unsafe abortions, right?

        Well, if just ONE woman changes her mind, based on the results of an ultrasound or seeing her fetus move in HER/; then maybe, just maybe the law is worth having on the books. FOR ALL TRIMESRERS

      2. TeamRNs: You are, presumably, a woman. You appear to consider yourself fairly smart. Do you think that if you decided to abort a pregnancy, you would appreciate being force-fed emotionally manipulative information based on the assumption that you’re a drooling retard unaware of the fact that you were getting an abortion?

        Women know they’re getting abortions when they get abortions. You don’t know better than any woman what’s right for her; why in the world do you think you have the right to force guilt on a woman making a perfectly legal and private decision?

      3. Lexa, I don’t care to dignify your comment with a response, other than to say that I don’t presume to know what is best for one woman. Only she knows what is best for her; I don’t see what I said that is intended to “force guilt” on a woman who is intent on having an abortion.

        If you think that asking her to wait the few hours while the US is read, is “forcing guilt” then it is HER GUILT- not mine.

      4. “No, my specialty is not ob/gyn, but this is an issue that SHOULD come into play at ALL times during a pregnancy and considered abortion.”

        Fetal position/cord placement should come into play in 1st trim abortions because, why?

        “The goal in this ‘exercise’ is to have fewer unsafe abortions, right?”

        A legitimate medical test has 1) an indication, 2) a validated technique, 3) a set of relevant values, and, last but not least, requires the patient’s consent. Not one of these requirements is satisfied by this U/S law.

        As to the goal of this nonmedical, unconsented vaginal probe (or “exercise”, as you call it), according to the law “fetal ultrasound imaging shall be performed prior to the abortion to confirm the gestational age”. There is no data showing that, once you have an EGA, a mandatory, nonmedical U/S improves the outcome.

        “Well, if just ONE woman changes her mind, based on the results of an ultrasound or seeing her fetus move in HER/; then maybe, just maybe the law is worth having on the books. FOR ALL TRIMESRERS”

        Really, you think it’s worth it to perform unconsented, invasive procedures without a medical indication on patients? So, what procedure should we perform on a pregnant patient who’s decided to carry to term, without her consent, just on the off chance that she might change her mind and terminate? A mandatory episiotomy, perhaps?

    2. Most abortions are done prior to being able to see position (they’re still attached to the lining) and the sac is pretty much the cord.

  5. Thanks for reviewing the medical evidence. My state legislature passed this law over the strident objections of the state medical association and an appeals court judge overturned an injunction delaying implementation. At the same time family planning funds were cut by 2/3. Politically motivated decisions make bad public policy.

  6. These laws are not enacted by ill-informed politicians, as you alluded, but by ideologically-driven politicians.

  7. So let me get this straight…a women views the living baby on an ultrasound and has NO difference in choosing an option other than abortion. That’s riduculous to even print. I cannot believe for a minute that seeing your own child on an ultrasound wouldn’t influence your decision to abort or not. I think the doctor is woking on opinion and not fact.

    1. Please re-read the post. I referenced the study that shows viewing the ultrasound had no effect for the women who chose to view it. In this study women were not forced to view. They were given the opportunity, and of the significant percentage who asked to see the image, most found it a positive experience.

      Again, it’s a study. I focus on evidence based medicine. I am not reporting my opinion, except at the end when I questioned how ultrasound laws supported the idea of smaller government.

    2. Your personal opinion disagrees with the facts discovered during studies of the matter, so it must be ridiculous to print, and you cannot believe it. This sort of attitude is why we have these laws that exist or are trying to exist in the first place — politicians who make their living doing things based on beliefs that have no grounding in reality at all.

    3. “Your personal opinion disagrees with the facts discovered during studies of the matter, so it must be ridiculous to print, and you cannot believe it.”

      Blade, I’m a woman and can forsee the eventuality of which you speak, but I could also come to the same conclusion as Dr. Jen did. But, that would mean allowing my emotions to taint my iactions.

      This physician takes a completely different view on this issue than you. Unfortunately, I imagine the facts that were discussed, were evaluated by panel of like-minded, liberal judges.statisticians.

    4. Have you ever had a ultrasound that required the transvaginal device? I still have the picture, and looked at again recently. I couldn’t really distinguish much then and still don’t now. I’m not surprised at the results of the study at all.

      1. And a little P.S. to that. The procedure is invasive and painful. Mine was performed by an Ob-Gyn who is an expert in high risk pregnancies. She knew what she was doing, was empathetic and gentle, and it was still incredibly unpleasant. This is a punitive requirement, and nothing less.

    5. I’m a physician (not ob/gyn), and had 2 high risk pregnancies in my 40’s. My first pregnancy was spontaneously aborted. My second and third had ultrasound after ultrasound from the moment the pregnancy strip was positive. In the later ultrasounds, the anatomy was recognizable to my trained eye. The blastomere phase not so much. Most women wanting an early abortion would look at an early ultasound and be reassured that it wasn’t a human yet.

    6. Read the study referenced in the citation Dr Jen presented. Bear in mind, the full text is likely behind a paywall unless you are at an institution. The abstract states a study size of 350 individuals and not one changed their mind. No interpretation is needed for those results, its either they changed their mind, or they didn’t.

  8. I am pro-choice. I thing abortion is terrible. I have never assisted at one, never suggested someone have one performed. I have, however, provided excellent care both before and after the procedure to women who chose to abort their fetus.

    I have never told someone that they must have the same beliefs as I, and I am against any legislature that restricts a woman’s choice to believe and act as she’s fit.

    Evidence of the catastrophic consequences to women’s health, of increased and preventable female mortality, where abortion cannot be legally obtained is ample. It’s a hard and painful call for me, but thankfully it’s not my call to make. The state must not legislate based on religious tenets. Period, end of paragraph.

    It is unbelievable to me that this religiously coercive issue is on the table in the US in 2012.

  9. It is so sad that people who do not know anything about this topic are supposed to create laws about it. Obviously, abortions will not stop, regardless of laws trying to make it more difficult. In my opinion, it will only increase the amount of risky abortions, leading to a higher number of deaths and injuries that should never have to happen to anyone.

  10. Thank you again for your sanity and commonsense on this issue. Thank you for referring to facts and science rather than hysteria and idiocy – Dana Loesch likening an unwanted internal ultrasound to the joys of consensual sex is springing to mind.

  11. Great article, Dr Jenn! As the US creates these issues on abortion, as well as, birth control, family planning, we only need to look north to see our Canadian neighbors have abortion available. Fewer women actually have abortions. Isn’t that the real objective?

  12. Great article, and I will be sharing. I was intrigued by the canadian abortion info, and it confirms my instincts. I am appalled by these laws, and thank you for writing this.

  13. Bad news for those of you here who henpecked a single study and tried to make a fact out of it..

    “did giving women the
    opportunity to view their unborn fetus reduce the probability that they would have an abortion? Most prolife groups believe that is the case. Most pro-choice groups also believe it to be true, although they believe
    that these laws are unconstitutional. Results of the present study suggest, however, that both groups are
    correct; ultrasound requirement laws reduce the odds of a woman having an abortion quite substantially.”

    1. I read the study you posted. All it does is compare rates of abortion in states that have ultrasound laws with rates of abortion in states that do not have ultrasound laws. Until they evaluate what other abortion-restricting laws might have been passed concurrent with these laws (often waiting periods, for example), this data is not helpful in determining whether viewing ultrasounds deters abortions. As we all know (I hope) correlation does not equal causation.

    2. HALLELUIAH! Someone posted an actual article….one with cited sources and everything! Which is more than I can say about the author of this article, I still cant find it.

      1. The number of abortions in the state is not simply a reflection of a law. Restrictions may cause women to go out of state. Pregnancy rates in teenagers are down across the country, and teen pregnancies are more likely unplanned and therefore more likely to end in abortion. So, simply saying that the # of abortions in a state has dropped means only that, there is no cause that can be cleaned from the information nor do we know if that truly reflects the abortion rate as some women may travel out of state.

      2. Thousands of lives have been saved in Virginia. Full stop.

        Pregnancy Centers report that they end up seeing many of these women who have changed their mind. While some travel out of state is always possible (where they would ALSO get an ultrasound as a matter of standard procedure). The new informed consent law has had its desired effect and lowered the abortion rate dramatically. THAT is what really has the pro abortion folks angry.

        Also, you are likely (purposefully) confusing teen BIRTH rates with teen PREGNANCY rates. This is also a very common way the abortion industry confuses people with something that looks like progress – while lifting their sales numbers. So far, you have been very facts averse – so this is nothing new. You WANT to think that a sudden, dramatic reduction in abortions is because women are fleeing to MD or DC. But yet the same ultrasounds happen to them there, often with the ADDED requirement of the vaginal probe. So WHY would they do that when the vaginal probe is only an option for them in Virginia?

        This is the same sort of thing going on with the preterm birth link. The AMA and ACOG continue to be deniers. They know what happens in the courts the minute they give in and finally stop their war against science. The tobacco industry went through the same, long process..

  14. Hi Dr. Jen I really liked your article. You are right about women not changing their mind about getting an abortion even after looking at the ultrasound. I know because I use to work at Planned Parenthood. I think that even though there “is a growing body of literature suggesting medical abortion can safety be accomplished without an ultrasound for 98% of women” that doctors will not do away with vaginal ultrasounds before a medication abortion. Patients always had to come back in 2 weeks to get another vaginal ultrasound to make sure they weren’t pregnant anymore. You need a before and after ultrasound pic to make sure the pregnancy has passed. I think more women need to be told that a vaginal ultrasound is a normal part of the abortion procedure. That the doctor prefers the ultrasound to a physical exam because it is more accurate.

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