Intact dilation and extraction

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Intact dilation and extraction (IDX or Intact D&X), is a surgical abortion wherein an intact fetus is removed from the womb via the cervix. The procedure may also be used to remove a deceased fetus (due to a miscarriage) that is developed enough to require dilation of the cervix for its extraction. This particular method of abortion — the removal of the fetus from the womb fully intact — has made it highly controversial. Though the procedure has a low rate of usage, representing for example 0.17% of all abortions in 2000 according to an Alan Guttmacher Institute survey,[1] it has developed into a focal point of the abortion debate.

Partial-birth abortion (PBA) is a non-medical, colloquial term used to refer to some late-term abortion procedures.[2] This term also has been defined by federal statute. While the term partial-birth abortion mainly refers to the intact dilation and extraction procedure, courts have found that legislation intended to ban so-called partial-birth abortions could be interpreted to apply to some dilation and evacuation (D&E) procedures.[3] Though sometimes performed during the same developmental stage wherein most IDX procedures are done, D&E is a separate procedure.

Contents

[edit] Terminology

The term dilation and extraction, or D&X, was coined by Cincinnati physician W. Martin Haskell, MD in a monograph that was distributed by the National Abortion Federation in September of 1992.[4] Haskell's term was a variation on intact dilation and evacuation (shortened to intact D&E), the term preferred by Dr. James McMahon, who developed the procedure in 1983 as an alternative to dilation and evacuation or D&E.[5] The American College of Obstetricians and Gynecologists later introduced a hybrid of the two terms, settling on Intact D&X. The medical term Intrauterine Cranial Decompression is also used in reference to the procedure.

The non-medical term Partial-birth Abortion was coined in 1995 by pro-life congressman Charles Canady (R-Fla)[6] and is primarily used in political discourse — chiefly regarding the legality of abortion in the United States. The term's first use may be from the original proposed Partial-Birth Abortion Ban, which circulated in discussion through the first half of 1995 and was formally introduced by the congressman on 14 June 1995.[7] Keri Folmar, the lawyer responsible for the bill's language, says the term developed in early 1995 in a meeting between her, Charles T. Canady, and National Right to Life Committee lobbyist Douglas Johnson.[8] "Partial-birth abortion" was first used in the media on 4 June 1995 in a Washington Times article covering the bill.[9]

There is debate over use of the term "partial-birth abortion". Those who oppose the term consider it a political term used to frame the argument in a way which is favorable to those who seek greater legal restrictions, or a total ban, on this or all abortion procedures, and have called the alleged political framing "partial truth abortion." [10] Doctors "have been successfully sued for failure to refer patients for late-term abortions in cases of fetal abnormalities."[11]

A more explicit non-medical term, Brain-suction Abortion, was used in a 1995 Ohio bill that sought to ban the procedure.

[edit] Intact D&X surgery

Preliminary procedures are performed over a period of 2–3 days, to gradually dilate the cervix using laminaria tents (sticks of seaweed which absorb fluid and swell). Sometimes drugs such as synthetic pitocin are used to induce labor. Once the cervix is sufficiently dilated, the doctor uses an ultrasound and forceps to grasp the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is referred to by some people as the 'partial birth' of the fetus. The doctor subsequently extracts the rest of the fetus, usually without the aid of forceps, leaving only the head still inside the birth canal. An incision is made at the base of the skull and a suction catheter is inserted into the cut. The brain tissue is removed, which causes the skull to collapse and allows the fetus to pass more easily through the birth canal. The placenta is removed and the uterine wall is vacuum aspirated using a suction curette.[12]

In an article entitled "Did I Violate the Partial-Birth Abortion Ban?" (Slate, Oct. 22, 2003), abortion provider Warren Hern described a procedure that might be interpreted as falling into the category:

Earlier this year, I began an abortion on a young woman who was 17 weeks pregnant. Because of the two days of prior treatment, the amniotic membranes were visible and bulging. I ruptured the membranes and released the fluid to reduce the risk of amniotic fluid embolism. Then I inserted my forceps into the uterus and applied them to the head of the fetus, which was still alive, since fetal injection is not done at that stage of pregnancy. I closed the forceps, crushing the skull of the fetus, and withdrew the forceps. The fetus, now dead, slid out more or less intact.

—Warren Hern, Warren M. Hern

[edit] Circumstances in which the procedure is performed

IDX, along with dilation and evacuation (D&E), early induction of labor, and rare procedures such as saline abortions, are only used in the late stages of pregnancy. Late-term abortions (abortions at 21 weeks or later) account for 1.4% of all abortions in the USA.[13] Intact D&X procedures are used in approximately 15% of late-term abortion cases. This calculates to between 2,500 and 3,000 per year, using data from the Alan Guttmacher Institute for the year 2000. They are typically performed between the twentieth and twenty-fourth week of gestation.[14]


Women choose to have late-term abortions for a variety of reasons, such as not knowing they were pregnant earlier in the pregnancy and diagnosis of a fetal abnormality late in the pregnancy. Once the decision to have a late-term abortion has been made, a woman or doctor may choose IDX over other available late-term abortion procedures because:

  • The woman does not have to experience labor.
  • The woman does not have to undergo abdominal surgery.
  • The procedure results in a largely intact body over which the parents may grieve.[8]
  • Sharp instruments are inserted into the uterus fewer times than in a D&E abortion.
  • The fetus may have hydrocephalus, where the head may expand to a radius of up to 250% of a normal skull at birth, making it impossible for it to pass through the cervix. If live birth is desired, the physician may drain the excess fluid in utero using a syringe, or a caesarian section with a larger than usual incision can be used. If abortion is desired, D&X may be the simplest procedure.


Reasons a woman or physician may not choose IDX, opting instead for another abortion procedure, include:

  • IDX requires a larger dilation of the cervix than D&E.
  • Podalic version (turning the fetus into a breech position) can be dangerous to the woman.
  • The incision in the fetal skull is made blind; the physician may miss and injure the woman's cervix.

[edit] Controversy

IDX is particularly a target of self-described pro-life advocates because they believe the procedure most clearly illustrates their contention that abortion, and especially late-term abortion, is immoral. Critics consider the procedure tantamount to infanticide,[15] or murder, a position which many in the pro-life lobby extend to cover all abortions.[16] Many advocates, both for and against abortion rights, see the IDX issue as a central battleground in the wider abortion debate, representing an attempt to set a legal precedent so as to gradually erode access to all abortion methods.[17]

The procedure itself is also controversial. Dr. Martin Haskell, who made the National Abortion Federation presentation, called it "a quick, surgical outpatient method" for late second-trimester and early third-trimester abortions.[4] The Partial-Birth Abortion Ban Act of 2003 describes it as "a gruesome and inhumane procedure that is never medically necessary,"[18] although self-described pro-choice groups argue that it is more humane than D&E, the most common second-trimester abortion method, and some doctors report medical necessity for the procedure.

[edit] Legal and political situation in the United States

[edit] Federal law

Main article: Partial-Birth Abortion Ban Act

Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. Congress passed two such measures by wide margins during Bill Clinton's presidency, but Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful.

A major part of the legal battle over banning the procedure relates to health exceptions, which would permit the procedure in special circumstances. The 1973 Supreme Court decision Roe v. Wade, which declared many state-level abortion restrictions unconstitutional, allowed states to impose certain restrictions on second- and third-trimester abortions. The companion ruling, Doe v. Bolton, required that states' restrictions on abortions must provide an exception for the health of the woman, and defined health to include mental as well as physical health, though in his concurring opinion Chief Justice Burger wrote, "plainly, the Court today rejects any claim that the Constitution requires abortions on demand". In practice, the Supreme Court has found most attempts to legislate restrictions on abortion to be in violation of Roe v. Wade.

In 2003, the Partial-Birth Abortion Ban Act (HR 760, S 3) was signed into law; the House passed it on October 2 with a vote of 281-142, the Senate passed it on October 21 with a vote of 64-34, and President George W. Bush signed it into law on November 5.

The Act includes an exception for the life of the woman, but explicitly not for non-life-threatening health issues; opponents believe that this exception is too narrow and have mounted numerous legal challenges. Congress asserted that the procedure is never necessary for maternal health.

Beginning in early 2004, the Planned Parenthood Federation of America, the National Abortion Federation, and abortion doctors in Nebraska challenged the ban in United States District Courts in San Francisco, New York, and Lincoln, Nebraska, respectively. All three District Courts ruled the ban unconstitutional that same year, and their respective appellate courts (Ninth, Second, and Eighth) affirmed these rulings on appeal. The Supreme Court is currently considering the case of Gonzales v. Carhart, and a decision is expected by July of 2007. The law has yet to be successfully enforced, and is on hold pending the outcome of the Supreme Court case.

[edit] State law

Many states have bans on late-term abortions which apply to the IDX procedure if it is performed after viability.

Many states have also passed bans specifically on the IDX procedure. The first was Ohio, which in 1995 enacted a law that referred to the procedure as dilation and extraction. In 1997, the United States Court of Appeals for the Sixth Circuit found the law unconstitutional on the grounds that it placed a substantial and unconstitutional obstacle in the path of women seeking pre-viability abortions in the second trimester.

Between 1995 and 2000, 28 more states passed Partial-Birth Abortion bans, all similar to the proposed federal bans and all lacking an exemption for the health of the woman. Many of these state laws faced legal challenges, with Nebraska's the first to reach decision in Stenberg v. Carhart. The Federal District Court held Nebraska's statute unconstitutional on two counts. One being the bill's language was too broad, potentially rendering a range of abortion procedures illegal, and thus, creating an undue burden on a woman's ability to choose. The other count was the bill failed to provide a necessary exception for the health of the woman. The decision was appealed to and affirmed by both the Eighth Circuit and the Supreme Court on June 2000, thus resolving the legal challenges to similar state bans nationwide.

Since the Stenberg v. Carhart decision, Virginia, Michigan, and Utah have introduced laws that remain virtually identical to the unconstitutional Nebraska law. The Virginia and Michigan laws were similarly struck down due to broadness and the failure to provide a health exemption, Utah's law remains pending trial, though is unenforceable due to a court-issued preliminary injunction.

In 2000 Ohio introduced another "partial-birth abortion" ban. The law differed from previous attempts at the ban in that it specifically excluded D&E procedures, while also providing a narrow health exception. This law was upheld on appeal to the Sixth Circuit in 2003 on the grounds that "it permitted the partial birth procedure when necessary to prevent significant health risks."

In 2003 the Michigan Senate introduced Senate Bill No. 395. The bill, which would change the legal definition of birth, would in affect ban partial birth abortions. The definition of birth as defined in the bill was that once any part of the body had passed beyond the vaginal plane of introitus it is considered a birth. The bill included an exemption for the mother's health. The bill was passed by both the Senate and House of Representatives but was vetoed by the governer. The veto was then overturned by a citizen initiative, which collected about four hundred sixty thousand signatures. The law was ruled unconstitutional in September 2005 and is currently being appealed.[19]

[edit] Legal and political situation in the United Kingdom

Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologists' (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."[20]

[edit] References

  1. ^ Guttmacher.org Abortion Incidence and Services in the United States in 2000
  2. ^ D & X/PBA Procedures: Introduction. religioustolerance.org. Accessed April 14, 2006.
    Statement on So-Called "Partial Birth Abortion" Law. The American College of Obstetricians and Gynecologists. Accessed April 17, 2006.
    Unconstitutional "Partial-Birth" Abortion Ban. Religious Coalition for Reproductive Choice. Accessed April 14, 2006.
    Late-Term Pregnancy Termination Techniques. American Medical Association. Accessed January 15, 2007.
  3. ^ Abortion Bans: Myths and Facts. American Civil Liberties Union. Accessed April 14, 2006.
    Stenberg v. Carhart, 530 U.S. 914 (2000)
  4. ^ a b Haskell, Martin. Dilation and Extraction for Late Second Trimester Abortion. Presented at the National Abortion Federation Risk Management Seminar, September 13, 1992.
  5. ^ Owner of Bombed Atlanta Nightclub is Sister of Abortion Doctor. Feminist Daily News Wire, February 26, 1997.
  6. ^ Alex Gordon. "The Partial-Birth Abortion Ban Act of 2003". Harvard Journal on Legislation. Volume 41, Number 2, Summer 2004. (see footnote 15)
  7. ^ H.R.1833. To amend title 18, United States Code, to ban partial-birth abortions.
  8. ^ a b Gorney, Cynthia. Gambling With Abortion. Harper Magazine, November 2004.
  9. ^ FOX News toes GOP line, using the term "partial birth abortion." Media Matters For America, Mon Dec 13, 2004.
  10. ^ Miranda Kennedy (March/April 2000). Partial Truth Abortion Coverage. Fairness and Accuracy in Reporting. Retrieved on 2006-09-14.
  11. ^ Trupin, Suzanne R. [Abortion http://www.emedicine.com/MED/topic5.htm] emedicine.com. Accessed April 25, 2006.
  12. ^ "Surgical Abortion Procedures" American Pregnancy Association. Accessed April 14, 2006.
    Haskell, Martin. "Dilation and Extraction for Late Second Trimester Abortion." Presented at the National Abortion Federation Risk Management Seminar, September 13, 1992
  13. ^ Abortion Surveillance — United States, 2002 CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Accessed April 14, 2006.
  14. ^ Abortion Incidence and Services in the United States, 1995-1996. Accessed April 17, 2006.
  15. ^ Koukl, Gregory. Partial-Birth Abortion Is Not About Abortion. Stand to Reason. Accessed April 25, 2006.
    White, Deborah. Pros & Cons of Partial Birth Abortions About.com. Accessed April 25, 2006.
  16. ^ The Official Point of View of the Romanian Orthodox Church on Abortion (summery). The Romanian Patriarchate. Accessed April 25, 2006.
    Achacoso, Jaime B. A Sin and a Crime Catholic.com. Accessed April 25, 2006.
    Gonzalez, Ramon. Pro-life teens challenged Western Catholic Reporter. October 23, 2000. Accessed April 25, 2006.
  17. ^ Slippery Slope: Democratic Wavering in the Battle for Reproductive Rights. PERRspectives.com. February 25, 2004. Accessed April 25, 2006.
    Strategic Initiatives The Rockridge Institute. Accessed April 25, 2006.
  18. ^ 108th Congress, 1st Session, S.3. Partial Birth Abortion Ban Act of 2003.
  19. ^ Right to life of Michigan legal birth definition act
  20. ^ Text of a written answer to a parliamentary question at The House of Lords Hansard. Accessed 7th September 2006

[edit] See also

[edit] External links

[edit] Legislation, Testimony, and Court Decisions

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