Late termination of pregnancy

Late termination of pregnancy (TOP),^[1] also known as postviability abortion,^[2] induced termination of pregnancy (ITOP),^[3] or simply abortion^[4] are terminations of pregnancy which are 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]

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 foetal abnormality.^[9]
• 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.^[10]
• England and Wales: In 2005, 9% of abortions occurred between 13 and 19 weeks, while 1% occurred at or over 20 weeks.^[11]
• New Zealand: In 2003, 2.03% of induced abortions were done between weeks 16 and 19, and 0.56% were done over 20 weeks.^[12]
• 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.^[13] Between February 15, 2010 and December 1, 2011, a total number of ten abortions were performed between 22 to 24 weeks. These have been declared illegal by The Norwegian Directorate of Health.^[14]
• Scotland: In 2005, 6.1% of abortions were done between 14 and 17 weeks, while 1.6% were performed over 18 weeks.^[15]
• Sweden: In 2005, 5.6% of abortions were carried out between 12 and 17 weeks, and 0.8% at or greater than 18 weeks.^[16]
• 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.^[17] 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.^[17] 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.^[18]

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 new study in 2013 shows 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."^[19]

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.^[20]

In addition, another 44 of the 152 most populous countries restricted abortions after a particular gestational age:^[20]

• 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 (additional restrictions after 18 weeks), 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 and Britain)
• 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.^[21] 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.^[22] 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.^[20]

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.^[23] 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.^[23] 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."^[24]

Eighteen states prohibit abortion after a certain number of weeks' gestation (usually 22 weeks from the last menstrual period).^[23] 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.^[25] 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".^[26]

Ten states (although Florida's enforcement of such laws are under permanent injunction) require a second physician to approve.^[23] 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".^[27] 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.^[23]

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.^[23] 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.^[28]

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"

Abortions done for fetal abnormality are usually performed with induction of labor or with IDX; elective late-term abortions are usually performed with D&E.

Live birth

Although it is very uncommon, women undergoing abortion after 18 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).^[29][30][31] Longer term survival is possible after 22 weeks.^[32]

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.^[33][34][35] Induced fetal demise before termination of pregnancy after 20–21 weeks gestation is recommended to avoid this.^{[36][37][38][39][40]}

References

External links

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