Late termination of pregnancy

Late termination of pregnancy
Intervention

Late termination of pregnancy (TOP),^[1] also known as postviability abortion,^[2] induced termination of pregnancy (ITOP),^[3] or simply abortion^[4] is a termination of pregnancy that is performed during a later stage of pregnancy. Late termination of pregnancy is more controversial than abortion in general because it results in the demise of a fetus that is more developed and sometimes able to survive independently. Given the complex, gradual nature of human fetal development, the definition of "late" in this context is not precise, and different medical publications have discussed the varying gestational age points that can be involved.

Definition

A late termination of pregnancy often refers to an induced ending of pregnancy after the 20th week of gestation. The exact point when a pregnancy becomes late-term, however, is not clearly defined. Some sources define an abortion after 16 weeks as "late".^[5][6] Three articles published in 1998 in the same issue of the Journal of the American Medical Association could not agree on the definition. Two of the JAMA articles chose the 20th week of gestation to be the point where an abortion procedure would be considered late-term.^[7] The third JAMA article chose the third trimester, or 27th week of gestation.^[8]

The point at which an abortion becomes late-term is often related to the "viability" (ability to survive outside the uterus) of the fetus. Sometimes late-term abortions are referred to as post-viability abortions. However, viability varies greatly among pregnancies. Many pregnancies are viable after the 27th week, and no pregnancies are viable before the 21st week. Everything in between is a "grey area".^[8]

Mental health

While a single first-trimester abortion carried no more mental health risk than carrying a pregnancy to term, abortion could not be proven safe in other cases as far as mental health was concerned. Women who terminate a pregnancy because of abnormalities discovered through fetal screenings have a similar risk of negative mental health outcomes as women who miscarry a wanted pregnancy or experience a stillbirth or the death of a newborn.^[9]

Incidence

Histogram of abortions by gestational age in England and Wales during 2004.

Abortion in the United States by gestational age, 2004. (Data source: Centers for Disease Control and Prevention)

• Australia: As of 2015, South Australia is the only Australian state or territory to keep reliable abortion statistics. During 2012, 92% of abortions were performed before 14 weeks' gestation, 6% between 14–20 weeks, and 2% (n=96) at a later stage. Of the 96 abortions carried out beyond 20 weeks, 53 were due to actual or probable fetal abnormality.^[10]
• Canada: During the year 2009, 29% of induced abortions were performed before 8 weeks, 41% at 9 to 12 weeks, 7% at 13 to 16 weeks and 2% over 21 weeks.^[11]
• England and Wales: In 2015, 8% of abortions occurred after 12 weeks; 0.1% occurred at or over 24 weeks.^[12]
• New Zealand: In 2003, 2.03% of induced abortions were done between weeks 16 and 19, and 0.56% were done over 20 weeks.^[13]
• Norway: In 2005, 2.28% of induced abortions were performed between 13 and 16 weeks, 1.24% of abortions between 17 and 20 weeks, and 0.20% over 21 weeks.^[14] Between February 15, 2010 and December 1, 2011, a total number of ten abortions were performed between 22 and 24 weeks. These have been declared illegal by The Norwegian Directorate of Health.^[15]
• Scotland: In 2005, 6.1% of abortions were done between 14 and 17 weeks, while 1.6% were performed over 18 weeks.^[16]
• Sweden: In 2005, 5.6% of abortions were carried out between 12 and 17 weeks, and 0.8% at or greater than 18 weeks.^[17]
• United States: In 2003, from data collected in those areas that sufficiently reported gestational age, it was found that 6.2% of abortions were conducted between 13 and 15 weeks, 4.2% between 16 and 20 weeks, and 1.4% at or after 21 weeks.^[18] Because the Centers for Disease Control and Prevention's annual study on abortion statistics does not calculate the exact gestational age for abortions performed past the 20th week, there are no precise data for the number of abortions performed after viability.^[18] In 1997, the Guttmacher Institute estimated the number of abortions in the U.S. past 24 weeks to be 0.08%, or approximately 1,032 per year.^[19]

Reasons

United States

In 1987, the Alan Guttmacher Institute collected questionnaires from 1,900 women in the United States who came to clinics to have abortions. Of the 1,900 questioned, 420 had been pregnant for 16 or more weeks. These 420 women were asked to choose among a list of reasons they had not obtained the abortions earlier in their pregnancies. The results were as follows:^[5]

• 71% Woman didn't recognize she was pregnant or misjudged gestation
• 48% Woman found it hard to make arrangements for abortion
• 33% Woman was afraid to tell her partner or parents
• 24% Woman took time to decide to have an abortion
• 8% Woman waited for her relationship to change
• 8% Someone pressured woman not to have abortion
• 6% Something changed after woman became pregnant
• 6% Woman didn't know timing is important
• 5% Woman didn't know she could get an abortion
• 2% A fetal problem was diagnosed late in pregnancy
• 11% Other

A study in 2013 showed that most women seeking late term 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 and nulliparous." The study data did not include woman who were having abortions "on grounds of fetal anomaly or life endangerment."^[20]

England and Wales

The NHS records the reasons given for abortions at all stages of development. In 2015, 2,877 abortions were performed at 20 weeks or above. Of these, 23 (0.8%) were performed to save the life of the pregnant woman, 1,801 (63%) were performed for mental or physical health reasons, and 1046 (36%) were performed because of foetal abnormalities. (The data do not sum up to 100% because multiple reasons could be recorded for each abortion.)^[21]

Legal restrictions

As of 1998, among the 152 most populous countries, 54 either banned abortion entirely or permitted it only to save the life of the pregnant woman.^[22]

In addition, 49 of the 152 most populous countries were without restriction as to reason, but 44 of these imposed limits after a particular gestational age:^[22]

• 12 weeks (Albania, Armenia, Azerbaijan, Belarus, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Cuba, Czech Republic, Denmark, Estonia, France, Georgia, Greece, Kazakhstan, Kyrgyz Rep., Latvia, Lithuania, Macedonia, Moldova, Mongolia, Norway, Russian Federation, Slovakia, Slovenia, South Africa, Ukraine, Tajikistan, Tunisia, Turkey, Turkmenistan, Uzbekistan, and Yugoslavia)
• 13 weeks (Italy)
• 14 weeks (Austria, Cambodia, Germany, Hungary, and Romania)
• 18 weeks (Sweden)
• 24 weeks (Singapore)
• viability (Netherlands and to some extent the United States)

In these countries, abortions after the general gestational age limit are allowed only under restricted circumstances, which include, depending on country, risk to the woman's life, physical or mental health, fetal malformation, cases where the pregnancy was the result of rape, or poor socio-economic conditions. For instance, in Italy, abortion is allowed on request up until 90 days, after which it is allowed only if the pregnancy or childbirth pose a threat to the woman’s life, a risk to physical health of the woman, a risk to mental health of the woman; if there is a risk of fetal malformation; or if the pregnancy is the result of rape or other sexual crime.^[23] Denmark provides a wider range of reasons, including social and economic ones, which can be invoked by a woman who seeks an abortion after 12 weeks.^[24] Abortions at such stages must in general be approved by a doctor or a special committee, unlike early abortions which are performed on demand. The ease with which the doctor or the committee allows a late term abortion varies significantly by country, and is often influenced by the social and religious views prevalent in that region.

Some countries, like Canada, China (Mainland only) and Vietnam have no legal limit on when an abortion can be performed.^[22]

United States

The United States Supreme Court decisions on abortion, including Roe v. Wade, allow states to impose more restrictions on post-viability abortions than during the earlier stages of pregnancy.

As of December 2014, forty-two states had bans on late-term abortions that were not facially unconstitutional under Roe v. Wade (i.e. banning all abortions) or enjoined by court order.^[25] In addition, the Supreme Court in the case of Gonzales v. Carhart ruled that Congress may ban certain late-term abortion techniques, "both previability and postviability".

The Supreme Court has held that bans must include exceptions for threats to the woman's life, physical health, and mental health, but four states allow late-term abortions only when the woman's life is at risk; four allow them when the woman's life or physical health is at risk, but use a definition of health that pro-choice organizations believe is impermissibly narrow.^[25] Assuming that one of these state bans is constitutionally flawed, then that does not necessarily mean that the entire ban would be struck down: "invalidating the statute entirely is not always necessary or justified, for lower courts may be able to render narrower declaratory and injunctive relief."^[26]

Eighteen states prohibit abortion after a certain number of weeks' gestation (usually 22 weeks from the last menstrual period).^[25] The U.S. Supreme Court held in Webster v. Reproductive Health Services that a statute may create "a presumption of viability" after a certain number of weeks, in which case the physician must be given an opportunity to rebut the presumption by performing tests.^[27] Because this provision is not explicitly written into these state laws, as it was in the Missouri law examined in Webster, pro-choice organizations believe that such a state law is unconstitutional, but only "to the extent that it prohibits pre-viability abortions".^[28]

Ten states (although Florida's enforcement of such laws are under permanent injunction) require a second physician to approve.^[25] The U.S. Supreme Court struck down a requirement of "confirmation by two other physicians" (rather than one other physician) because "acquiescence by co-practitioners has no rational connection with a patient's needs and unduly infringes on the physician's right to practice".^[29] Pro-choice organizations such as the Guttmacher Institute therefore interpret some of these state laws to be unconstitutional, based on these and other Supreme Court rulings, at least to the extent that these state laws require approval of a second or third physician.^[25]

Thirteen states have laws that require a second physician to be present during late-term abortion procedures in order to treat a fetus if born alive.^[25] The Court has held that a doctor's right to practice is not infringed by requiring a second physician to be present at abortions performed after viability in order to assist in the case of a living fetus.^[30]

Methods

There are at least three medical procedures associated with late-term abortions:

• Dilation and evacuation (D&E)
• Early labor induction (sometimes called "induction abortion")
• Intact dilation and extraction (IDX or D&X), sometimes referred to as "partial-birth abortion"

Live birth

Although it is very uncommon, women undergoing abortion after 25 weeks gestation sometimes give birth to a fetus that may survive briefly (occurring 0 to 13% or 0 to 50%, depending on the method and gestation).^[31][32][33] Longer term survival is possible after 22 weeks.^[34]

If medical staff observe signs of life, they may be required to provide care: emergency medical care if the child has a good chance of survival and palliative care if not.^[35][36][37] Induced fetal demise before termination of pregnancy after 20–21 weeks gestation is recommended to avoid this.^{[38][39][40][41][42]}

References

1. Graham, RH; Robson, SC; Rankin, JM (January 2008). "Understanding feticide: an analytic review.". Social science & medicine (1982). 66 (2): 289–300. doi:10.1016/j.socscimed.2007.08.014. PMID 17920742.
2. Guttmacher Institute. "State Policies in Brief, An Overview of Abortion Laws" (PDF). www.guttmacher.org. Guttmacher Institute. Retrieved 28 September 2015.
3. Duke, C. Wes (September 2009). "Challenges and Priorities for Surveillance of Stillbirths: A Report on Two Workshops". Public Health Rep. 124 (5): 652–659. PMC 2728657. PMID 19753943.
4. Roe v. Wade, 410 U.S. 113 (1972). Findlaw.com. Retrieved 2011-04-14.
5. Torres, Aida and Forrest, Jacqueline Darroch. (1988). Why Do Women Have Abortions. Family Planning Perspectives, 20 (4), 169-176. Retrieved April 19, 2007.
6. Weihe, Pál, Steuerwald, Ulrike, Taheri, Sepideh, Færø, Odmar, Veyhe, Anna Sofía, & Nicolajsen, Did. (2003). The Human Health Programme in the Faroe Islands 1985-2001. In AMAP Greenland and the Faroe Islands 1997-2001. Danish Ministry of Environment. Retrieved April 19, 2007.
7. Sprang, M.L, and Neerhof, M.G. (1998). Rationale for banning abortions late in pregnancy. Journal of the American Medical Association, 280 (8), 744-747.
   Grimes, D.A. (1998). The continuing need for late abortions. Journal of the American Medical Association, 280 (8), 747-750.
8. Gans Epner, J.E., Jonas, H.S., Seckinger, D.L. (1998). Late-term abortion. Journal of the American Medical Association, 280 (8), 724-729.
9. "Mental Health and Abortion". American Psychological Association. 2008. Retrieved April 18, 2012.
10. Pregnancy Outcome Unit, SA Health. (2014). . Retrieved July 10th, 2015.
11. Globe & Mail. (2012). Percentage distribution of induced abortions by gestation period. Retrieved December 7th, 2012.
12. Government Statistical Service for the Department of Health. (May 17, 2016). Abortion statistics, England and Wales: 2015. Retrieved October 20, 2016.
13. Statistics New Zealand. (January 31, 2005). Demographic Trends 2004. Retrieved April 19, 2007.
14. Statistics Norway. (April 26, 2006). Induced abortions, by period of gestation and the woman's age. 2005. Retrieved January 17, 2006.
15. The Norwegian Directorate of Health. (May 7, 2012). Senaborter etter 22. uke Retrieved May 11, 2012.
16. ISD Scotland. (May 24, 2006). Percentage of abortions performed in Scotland by estimated gestation. Retrieved May 10, 2007.
17. Nilsson, E., Ollars, B., & Bennis, M.. The National Board of Health and Welfare. (May 2006). Aborter 2005. Retrieved May 10, 2007.
18. Strauss, L.T., Gamble, S.B., Parker, W.Y, Cook, D.A., Zane, S.B., & Hamdan, S. (November 24, 2006). Abortion Surveillance - United States, 2003. Morbidity and Mortality Weekly Report, 55 (11), 1-32. Retrieved May 10, 2007.
19. Guttmacher Institute. (January 1997). The Limitations of U.S. Statistics on Abortion. Retrieved April 19, 2007.
20. Foster, Diana (December 2013). "Who Seeks Abortions at or After 20 Weeks?". Perspectives on Sexual and Reproductive Health. 45 (4): 210–218. doi:10.1363/4521013. Retrieved 9 September 2014.
21. Department of Health (17 May 2016). Report on abortion statistics in England and Wales for 2015 (PDF) (Report). p. 31 (Table 7b). Retrieved 2016-10-24.
22. Anika Rahman, Laura Katzive and Stanley K. Henshaw. A Global Review of Laws on Induced Abortion, 1985-1997, International Family Planning Perspectives (Volume 24, Number 2, June 1998).
23. http://www.ippfen.org/NR/rdonlyres/2EB28750-BA71-43F8-AE2A-8B55A275F86C/0/Abortion_legislation_Europe_Jan2007.pdf
24. "DENMARK". harvard.edu. Retrieved 13 October 2015.
25. Guttmacher Institute. (April 1, 2007). State Policies on Later-Term Abortions. State Policies in Brief. Retrieved April 19, 2007.
26. Ayotte v. Planned Parenthood, 546 U.S. 320 (2006).
27. Webster v. Reproductive Health Services, 492 U.S. 490 (1989).
28. NARAL Pro-Choice America. (2007). "Delaware." Who Decides? The Status of Women's Reproductive Rights in the United States. Retrieved April 19, 2007.
29. Doe v. Bolton, 410 U.S. 179 (1973).
30. Planned Parenthood Ass'n v. Ashcroft, 462 U.S. 476, 486-90 (1983).
31. "The Care of Women Requesting Induced Abortion. Evidence-Based Clinical Guideline no. 7" (PDF). Royal College of Obstetricians and Gynaecologists. November 2011. Retrieved 31 October 2015. RECOMMENDATION 6.21 Feticide should be performed before medical abortion after 21 weeks and 6 days of gestation to ensure that there is no risk of a live birth.
32. Society of Family Planning (February 2011). "Clinical Guidelines, Labor induction abortion in the second trimester". Contraception. 84 (1): 4–18. doi:10.1016/j.contraception.2011.02.005. Transient survival with misoprostol for labor induction abortion at greater than 18 weeks ranges from 0% to 50% and has been observed in up to 13% of abortions performed with high-dose oxytocin.
33. Fletcher; Isada; Johnson; Evans (Aug 1992). "Fetal intracardiac potassium chloride injection to avoid the hopeless resuscitation of an abnormal abortus: II. Ethical issues.". Obstetrics and Gynecology. 80 (2): 310–313. PMID 1635751. ... following later abortions at greater than 20 weeks, the rare but catastrophic occurrence of live births can lead to fractious controversy over neonatal management.
34. "Termination of Pregnancy for Fetal Abnormality" (PDF). Royal College of Obstetricians and Gynaecologists: 29–31. May 2010. Retrieved 26 October 2015. Death [of the fetus] may occur before delivery, either by the procedure undertaken by an obstetrician (feticide) or as a consequence of a compromised fetus being unable to tolerate induced labour. Death may also occur after birth either because of the severity of the abnormality for which termination was performed or because of extreme prematurity (or both)... Where the fetal abnormality is not lethal and termination of pregnancy is being undertaken after 22 weeks of gestation, failure to perform feticide could result in live birth and survival, an outcome that contradicts the intention of the abortion. In such situations, the child should receive the neonatal support and intensive care that is in the child's best interest and its condition managed within published guidance for neonatal practice.
35. Nuffield Council on Bioethics (2007). "Critical care decisions in fetal and neonatal medicine: a guide to the report" (PDF). Retrieved 29 October 2015. Under English law, fetuses have no independent legal status. Once born, babies have the same rights to life as other people.
36. Gerri R. Baer; Robert M. Nelson (2007). "Preterm Birth: Causes, Consequences, and Prevention. C: A Review of Ethical Issues Involved in Premature Birth". Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes;. In 2002, the 107th U.S. Congress passed the Born-Alive Infants Protection Act of 2001. This law established personhood for all infants who are born “at any stage of development” who breathe, have a heartbeat, or “definite movement of voluntary muscles,” regardless of whether the birth was due to labor or induced abortion.
37. Chabot, Steve (5 August 2002). "H.R. 2175 (107th): Born-Alive Infants Protection Act of 2002". govtrack.us. Retrieved 30 October 2015. The term ``born alive is defined as the complete expulsion or extraction from its mother of that member, at any stage of development, who after such expulsion or extraction breathes or has a beating heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, regardless of whether the umbilical cord has been cut, and regardless of whether the expulsion or extraction occurs as a result of natural or induced labor, cesarean section, or induced abortion.
38. "Practice Bulletin: Second-Trimester Abortion" (PDF). Obstetrics & Gynecology. 121 (6): 1394–1406. June 2013. doi:10.1097/01.AOG.0000431056.79334.cc. PMID 23812485. Retrieved 30 October 2015. With medical abortion after 20 weeks of gestation, induced fetal demise may be preferable to the woman or provider in order to avoid transient fetal survival after expulsion.
39. "Clinical Guidelines: Induction of fetal demise before abortion" (PDF). Contraception: a publication of Society of Family Planning. 81: 8. January 2010. doi:10.1016/j.contraception.2010.01.018. Retrieved 26 October 2015. Inducing fetal demise before induction termination avoids signs of live birth that may have beneficial emotional, ethical and legal consequences.
40. Committee on Health Care for Underserved Women (November 2014). "Committee Opinion 613: Increasing Access to Abortion". Obstetrics & Gynecology. 124: 1060–1065. doi:10.1097/01.aog.0000456326.88857.31. Retrieved 28 October 2015. “Partial-birth” abortion bans—The federal Partial-Birth Abortion Ban Act of 2003 (upheld by the Supreme Court in 2007) makes it a federal crime to perform procedures that fall within the definition of so-called “partial-birth abortion” contained in the statute, with no exception for procedures necessary to preserve the health of the woman...physicians and lawyers have interpreted the banned procedures as including intact dilation and evacuation unless fetal demise occurs before surgery.
41. "2015 Clinical Policy Guidelines" (PDF). National Abortion Federation. 2015. Retrieved 30 October 2015. Policy Statement: Medical induction abortion is a safe and effective method for termination of pregnancies beyond the first trimester when performed by trained clinicians in medical offices, freestanding clinics, ambulatory surgery centers, and hospitals. Feticidal agents may be particularly important when issues of viability arise.
42. "FIGO (International Federation of Gynecology and Obstetrics) Committee Report: Ethical aspects concerning termination of pregnancy following prenatal diagnosis.". International Journal of Gynecology and Obstetrics. 102 (102): 97–98. 2008. doi:10.1016/j.ijgo.2008.03.002. PMID 18423641. Termination of pregnancy following prenatal diagnosis after 22 weeks must be preceded by a feticide

External links

• "I Had An Abortion When I Was Six Months Pregnant"