Doctors weigh in on late-term abortions

Posted at 9:41 PM, Feb 06, 2019

President Donald Trump has called on Congress "to pass legislation to prohibit the late-term abortion of children." This came after he first accused New York lawmakers of cheering for "legislation that would allow a baby to be ripped from the mother's womb moments before birth" and then said embattled Virginia Gov. Ralph Northam "would execute a baby after birth."

With the recent passage of New York's new Reproductive Health Act and Northam's voiced support of a measure that would loosen restrictions on abortions later in pregnancy, the phrase "late-term abortion" has appeared in headlines, peppered conversations, fueled social media battles -- and now made it into a State of the Union address. But what exactly does this language mean?

CNN spoke with two ob-gyns to explain: Dr. Barbara Levy, vice president of health policy at the American College of Obstetricians and Gynecologists , a professional organization; and Dr. Jennifer Conti, a fellow with the advocacy group Physicians for Reproductive Health and co-host of The V Word podcast.

CNN: What does the phrase "late-term abortion" mean to you?

Dr. Barbara Levy: The phrase "late-term abortion" is medically inaccurate and has no clinical meaning. In science and medicine, it's essential to use language precisely. In pregnancy, to be "late term" means to be past 41 weeks gestation, or past a patient's due date. Abortions do not occur in this time period, so the phrase is contradictory.

Dr. Jennifer Conti: In obstetrics, we don't divide pregnancies into terms. "Late term" is an invention of anti-abortion extremists to confuse, mislead and increase stigma. The appropriate language is "abortions later in pregnancy."

CNN: When people speak about abortion later in pregnancy, are they referring to abortion in the third trimester or something else?

Levy: Generally, abortion later in pregnancy refers to abortion that happens at 21 weeks or later, so in the second or third trimester.

CNN: How common or uncommon are abortions at this stage of pregnancy?

Conti: According to the US Centers for Disease Control and Prevention , abortions after 21 weeks make up less than 1.3% of all abortions in the United States. This means that abortions that occur beyond 24 weeks make up less than 1% of all procedures.

CNN: Can you explain why abortions happen later in a pregnancy?

Conti: There are many reasons why women may need to access abortion later in pregnancy, including maternal health endangerment, diagnosis of fetal abnormalities or restrictive laws delaying earlier access to abortion care. Those exceptionally rare cases that happen after 24 weeks are often because a fetus has a condition that cannot be treated and will never be able to survive -- regardless of the gestational age or trimester.

It's this exact reason that it's nonsensical to legislate these cases: Nobody arrives at the decision to have an abortion after 24 weeks carelessly. Rather, it's the rare case of rapidly decompensating maternal heart disease or a delayed diagnosis of anencephaly, where the fetus forms without a complete brain or skull, that bring people to these decisions.

Levy: Abortions later in pregnancy typically occur because of two general indications: lethal fetal anomalies or threats to the health of the mother. Some fetal development problems or genetic anomalies do not show up or develop until later in pregnancy. Some examples might include anencephaly (described above) or limb-body wall complex, when the organs develop outside of the body cavity. With conditions like these, the fetus cannot survive out of the uterus.

Likewise, when conditions progress or appear that severely compromise a woman's health or life, abortion may be the safest, medically indicated procedure. These conditions can also reduce the possibility of fetal survival. They might include premature rupture of membranes (where the fluid surrounding the fetus is lost before labor), uterine infection, preeclampsia, placental abruption and placenta accreta. Women under these circumstances may have extensive blood loss or septic shock that can be fatal.

It's important to note, if a woman's health or life is at risk and the fetus is viable, delivery is pursued, not abortion.

In the case of either lethal fetal anomalies or complications that endanger a woman's life, it's essential that women and their physicians are able to consider the full range of appropriate treatments, whether that's abortion care, induction of labor or cesarean birth. Every pregnant woman's situation and medical condition are different, and there is no way to make a one-size-fits-all determination about the appropriate care.

No matter what, care must be compassionate and recognize that for many women, the choices they are facing are devastating and immensely complicated.

CNN: Can any woman simply choose to have an abortion late in her pregnancy?

Levy: Abortion later in pregnancy is a very complex decision and, often, a very emotional one. We know that women who make the decision to have an abortion do so in a considered, deliberate fashion. This is especially true for women who have abortions later in pregnancy who are often facing devastating fetal diagnoses or life-threatening conditions that may introduce a multitude of clinical considerations into their decision-making.

Moreover, the ob-gyns who provide later in pregnancy abortion care have very specific training both in the technical procedure, as well as ethical decision-making in complex clinical circumstances.

Conti: Federal law is meant to protect the right to abortion up to the point of viability (often thought of as 24 weeks from the last menstrual period), but numerous states have subsequently enacted harmful gestational age limits that are ideologically motivated and not based in science. Your right to an abortion is now absolutely based on the accident of your ZIP code.

If a person needs to end their pregnancy after 24 weeks, there are a limited number of places in the country where they can do that, and the approval process for that procedure is scrupulous.

CNN: Many states that impose gestational age limits for abortion do so with exceptions. Do exceptions do enough to alleviate your concerns?

Levy: The American College of Obstetricians and Gynecologists opposes undue political interference in the practice of medicine, including legislation that bans abortion at an arbitrary cutoff point. While exceptions are often suggested for gestational age bans, the fact is that it's impossible to predict every circumstance that might arise in pregnancy.

Additionally, exceptions can also generate significant confusion for health care providers attempting to interpret these laws and practice accordingly, particularly when they face criminal charges if they violate the law, even if accidentally.

It is an exceedingly precarious position between counseling patients on the most appropriate and compassionate care for their health and interpreting vague legal exceptions.

CNN: Are there other reasons access to abortion care concerns you?

Levy: Even in states where arbitrary gestational age restrictions do not exist, barriers to any abortion care are still very common. Many women in the United States live 100 miles or more from the nearest abortion care provider. Even if they are able to access a health care provider, they are likely to face other barriers to abortion care, like medically unnecessary ultrasounds, mandatory 24-hour waiting periods and two in-person trips to a clinic. And of course, for women living in states that ban coverage of abortion care in insurance plans, the procedure -- especially if they need to travel, take time off of work and/or secure child care -- may be prohibitively expensive. Federal funding for abortion care is also banned, except in extremely limited circumstances

For women who need abortion care in the third trimester, there are very few places across the country where this care is accessible, and it is very rarely covered by insurance. Typically, these procedures would cost in the thousands of dollars. Moreover, many women would have to travel by plane to reach these providers, so in addition to the cost of the care, they are incurring the cost of travel and lodging.

CNN: What do you wish people would think about when discussing this hot-button subject?

Levy: It's important to remember, whether in a discussion about abortion care or any other component of care, that these are complicated, nuanced circumstances that affect the course of real people's lives.

Particular to abortion care later in pregnancy, I would urge everyone to exercise more compassion. It's important to acknowledge that we simply cannot possibly know the circumstances of every pregnancy or the challenge of making decisions when things go terribly awry.

Abortion later in pregnancy is not used as an alternative to delivering healthy women's full-term, viable pregnancies. Additionally, it's callous to suggest that healthy women with viable pregnancies at term abruptly change their minds and seek abortion care as the solution.

CNN: What do you think are the biggest misunderstandings about this topic?

Conti: The majority of women having abortions are already mothers and are making the decisions they know to be best for their other children and their families.

One in four women will have an abortion by the time they're 45, which means that very likely, you know or love someone who has had an abortion. If you're not privy to them, it's likely because your outward judgment is isolating those people in your life.

As someone who used to self-identify as anti-choice, I can attest that the biggest misunderstanding about abortion is the framework of hypotheticals vs. reality. All pregnancies carry risks, but some much more than others, and it is the job of the patient to weigh risks and benefits in all medical decisions. Not politicians. Not journalists. Not strangers on Twitter.

Misleading hypotheticals show disregard and contempt for people who have had an abortion later in pregnancy. People who have abortions deserve empathy and understanding, not judgment.