Is Late-Term Abortion Ever Necessary?
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| Is late-term abortion ever a medical necessity? Or are there always other options available? | |||||||
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Mary L. Davenport, M.D. |  |
Tracy Weitz, Ph.D. | ||||
| American Association of Pro-Life Obstetricians and Gynecologists | Advancing New Standards in Reproductive Health | ||||||
| Dr. Mary Davenport is an obstetrician-gynecologist in private practice in El Sobrante, California. She is also a Fellow of the American College of Obstetrics and Gynecology. She is on the boards of the California Association of Natural Family Planning and is president-elect of the American Association of Pro-Life Obstetricians and Gynecologists. | Tracy Weitz, Ph.D., MPA, is director of Advancing New Standards in Reproductive Health (ANSIRH) and associate director for public policy at the UCSF National Center of Excellence in Women’s Health. She holds a Ph.D. in medical sociology from the University of California, San Francisco. | ||||||
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Is Late-Term Abortion Ever Necessary? Mary L. Davenport, M.D., FACOG Editor’s note: Dr. Davenport’s original article “Is Late-Term Abortion Ever Necessary” was published by the Family Research Council in June 2009. It is reprinted with permission. Dr. Weitz’s responses and Dr. Davenport’s subsequent replies were written for PublicSquare.net. Click on their names to read the dialogue. In the aftermath of the killing of George Tiller, the Kansas abortionist, on May 31, 2009, we have heard praises of his compassion and courage in performing late-term abortions. Before addressing the content of this article, I believe it is important to discuss the use of the phrase “late-term abortion.” As Dr. Davenport notes later in her article, “late-term abortion” is not a phrase used in medicine. Rather, it is a social/political term designed to confuse a complex issue. Roe v. Wade in 1973 set the boundaries for legal abortion in the United States, allowing abortion without restrictions in the first trimester and permitting restrictions in the second trimester to protect the pregnant woman’s health. Abortions after “viability” were allowed when the pregnancy threatened the pregnant woman’s health or life. In 1992 the Planned Parenthood v. Casey decision eliminated the distinction between the standards for first and second trimester regulations, allowing the state to regulate abortion prior to viability so long as those regulations did not create an undue burden on a woman’s right to abortion. No change was made to the protection for abortions after viability. Medical understandings of “viability” usually promote a subjective and case-specific determination, while popular lexicon tends to locate “viability” at around twenty-four weeks. However, as Dr. Davenport notes, the second trimester extends to the twenty-seventh week of pregnancy; thus, there is not a perfect overlap between the end of the abortions in the second trimester and abortions performed prior to viability. The phrase “late abortion” is most often used to refer to those abortions that bump up on the “viability” limit. Dr. David Grimes, a leading expert on abortion, advocates the use for this phrase for abortions after twenty weeks (Grimes, 1998). In contrast, a “term” pregnancy is thirty-seven weeks. As such, the addition of the modifier “term” to the phrase “late abortion” implies that abortions are occurring near that thirty-seven-week point in pregnancy. These misunderstandings become important because of how claims about “why women have abortions” are mobilized to generate support or opposition to abortion restrictions.
Three types of abortions are being contested:
It is my argument that abortion is often necessary in all of the above conditions. Evidence from research over several decades suggests that women are better off when they can choose the number and timing of their pregnancies (Boonstra, Gold, Richards, and Finer, 2006). Additionally, medical standards of care from the leading professional organizations suggest that abortion is a necessary option for certain medical conditions such as premature rupture of membranes and eclampsia [see American College of Obstetricians and Gynecologists (2002, 2007)]. Finally, abortion is beginning to be recognized internationally as a human right [see Zampas & Gher (2008)]. The article “Is Late-Term Abortion Ever Necessary?” was written to challenge the assumption that late abortions—in particular post-viability abortions—are unavoidable. In a medical or surgical abortion procedure, the death of the unborn is an intended result. Dr. Weitz is missing the main point that terminating a post-viability pregnancy for medical necessity does not require the death of the unborn baby. The very survival of infants of similar gestational ages to those who are aborted refutes the assertion that their intentional killing is necessary. As stated previously, post-viability terminations of pregnancy for medical necessity can be achieved by cesarean section or induction of labor and typically consider health of both mother and baby. Consideration of the health and life of the mother and the baby are the gold standard of obstetrical care. It is true that very rarely pregnancy must be terminated for maternal life considerations prior to viability, but the death of the fetus should be an unintended consequence of the termination of pregnancy, not the purpose of the intervention.
Weitz did not provide any medical evidence that intentional killing of the fetus after viability is necessary. Her statement that she thinks women are “better off” when they can have late abortions on demand does not mean they are medically necessary. The fact that certain political organizations have stated that abortion is a “human right” is irrelevant. Other political documents, including some national constitutions, state that unborn human beings possess the right to life. I appreciate Dr. Davenport’s clarification that the focus of her article is the need for post-viability abortions. Unfortunately, throughout her arguments she intentionally blurs the distinction between “late abortions” and “post-viability abortions.” They are not the same thing. Late abortions in the second trimester happen prior to fetal viability and are not restricted by law. Abortions after the point of potential viability (usually assumed at twenty-four to twenty-six weeks), as she notes, are regulated differently. They are allowed when the life or health of the pregnant women is at risk or when the fetus is significantly impaired. Conflating the two types of abortions is inappropriate. As is evident from Dr. Davenport’s language, she is opposed to all abortions and as such may not recognize this distinction, but it remains important because of how data is collected and clinical decisions are made. According to NARAL Pro-Choice Colorado, “Dr. Tiller was one of few doctors with the expertise necessary to provide safe, professional abortions under the most difficult of circumstances: when a woman who had wanted children was told late in her pregnancy that a severe fetal anomaly had developed or that continuing the pregnancy threatened her own life.” [1]
For example, Dr. Davenport continues to argue that most late abortions occur for non-medical reasons. To make this claim, she uses CDC, Guttmacher, and Hammond citations, which are for pre-viable abortions. This data does not support her argument that post-viable abortions occur for these same reasons. She absolutely cannot infer that abortions prior to viability and after viability occur for the same reasons given that the law limits post-viable abortions. Her claim that these are the best data we have does not matter. They are not data for abortions after the legal limit for viability. We don’t have that data and need to acknowledge that fact. The second example of her slippage is the misuse of my discussion of “better off.” The data I am referencing suggest that women as a whole are better off when they can choose the number and spacing of their children. This is an argument for all abortions, not post-viability abortions. Arguments for post-viability abortions center on the need for abortion based on the health of the pregnant woman or fetus. The third problem with the slippage is seen in the discussion of the link between abortion and subsequent preterm birth. Again, it is not abortions post-viability (i.e. after twenty-four weeks) that are discussed in the literature she references. Davenport is making an argument against all abortion, not later abortion. Detailed discussion of the problems with this literature is below. Davenport’s citation of a publication of the American Association of Pro-Life Obstetricians and Gynecologists as evidence of the link between abortion and preterm delivery is ironic. This fact sheet provides detailed information on the significant health consequences that arise from early delivery, including debilitating neurological impairment. This is the very medical evidence for later abortion that Davenport claims does not exist. As her own source points out, low birth weight and preterm birth “are the most important risk factors for infant mortality or later disabilities, as well as for lower cognitive abilities and greater behavioral problems. In addition to the huge human cost, the economic cost required to properly care for these premature babies is a severe challenge to medical care system.” The decision to deliver an extremely early fetus has significant medical risks. Women and their partners must be allowed to make decisions given the stark realities of the quality of life for most fetuses delivered early in the third trimester. There also exist medical reasons for post-viable abortions to preserve the health of the pregnant woman. They include the presence of hypertensive disorders in pregnancy (for which the only treatment is terminating the pregnancy) and premature rupture of membranes (which, if left untreated, can cause complete body infection and even death). Heart disease presents other medical reasons. For example, as Marfan syndrome can cause spontaneous dissection or rupture of the aorta, the most feared cardiovascular complications associated with pregnancy, clinical guidelines recommend pregnancy termination if a woman’s aortic root enlargement is greater than set limits (Warnes et al., 2008). Some cancer diagnoses can also necessitate the immediate termination of pregnancy. Dr. Tiller was one of only a few doctors who openly advertised that he performed procedures later in pregnancy. Many other physicians provide this care on a case-by-case basis in order to save a woman’s life or because the fetus is incompatible with life. These doctors, often maternal fetal medicine specialists, do not advertise themselves as “abortion providers.” What was unique about Dr. Tiller was that he was willing to be known for providing this service. This allowed many women to find him, often women without access to these specialists or whose physicians were constrained from providing this care because of institutional and state restrictions. Currently, one in six hospital beds is now under the ownership of religious institutions that prohibit abortion in all circumstances. [For more about how doctors cannot perform abortions they feel necessary for the health of their patients, see Freedman, Landy, and Steinauer (2008)]. New abortion regulations are making it harder to provide care later in the second trimester, thus further limiting women’s access to care [see Jones and Weitz (2009) for more discussion of these restrictions]. Former patients gave heart-wrenching testimonies of late-term abortion being their only alternative upon discovery of fatal birth defects. In his clinic’s video given to late-term abortion patients, Tiller welcomed women who came to him to “end a pregnancy early because of some serious disease process: cancer, lymphoma, diabetes, high blood pressure, heart disease,” as well as those who were bearing children with fetal anomalies.
One of the great successes of the women’s health movement are new models for collaborative decision making that challenge the once-guaranteed paternalism of medicine [see Morgen (2002) and Weisman (1998)]. Dr. Davenport seems to share support for these new models in her later critique of the misinformation women receive about the medical risks of continuing their pregnancies. However, here, as well as in several other places in the article, when a woman’s decision is for abortion, Dr. Davenport wholly negates her capacity to articulate her own health care needs. I believe it is important to take seriously women’s experiences receiving care from Dr. Tiller. One website collects these stories. They tell of women who, after consultation with physicians, their families, their communities, and their god, chose to obtain an abortion from Dr. Tiller. I encourage readers to reflect on these women’s experiences as told in their own words.
Weitz states that women who want abortions sometimes have difficulty finding providers and that some physicians are constrained by law or institutionally in performing all of the late abortions that they or their patients would like. Post-viability abortion procedures are restricted because they do not legitimately fall within the boundaries of medicine: to save lives, cure disease, or alleviate physical pain. In the U.S., judicial decisions unsupported by public opinion allow abortion much later and under much less serious circumstances than in most civilized nations in the world. The fact that some women and some physicians want to abort viable unborn infants does not mean that we should allow it or make it easy. Just as we do not allow infanticide because of poverty, birth defects, or maternal illness, we should not allow intentional killing of fetuses—particularly after viability—because this is in conflict with our fundamental beliefs about the sanctity of human life. The president of the Center for Reproductive Rights, a legal advocacy organization, claimed that the closing of Tiller’s clinic left “an immediate and immense void in the availability of abortion.”
But is late-term abortion (or any abortion) ever really necessary? Does the demise of a clinic performing late-term abortions leave a “void” that is harmful to women? The Tiller murder and the legislative and judicial hearings on partial-birth abortion have focused public attention on late-term abortion in the U.S. Late-term abortion is not an exact medical term, but it has been used to refer to abortions in the third trimester (28–39 weeks) or even second trimester abortions (13–27 weeks). According to less-than-perfect statistics collected by the Centers for Disease Control (CDC) and the Guttmacher Institute,[2] 12 percent of U.S. abortions, approximately 144,000 procedures a year, are performed after the first trimester, that is, more than 12 weeks elapsed time after the woman’s last menstrual period. About 15,600 abortions, 1.3 percent of the 1.2 million abortions in 2005, occur after the 20th week.[3] This data does not tell us how many abortions occur after the expected point of viability.
Late-term abortions have been part of the American landscape since the Supreme Court issued its landmark 1973 rulings in Roe v. Wade and Doe v. Bolton—both issued on the same day. It is important to remember that abortion in the U.S. predates the Roe decision. Many women obtained abortions before 1973, some with medical authorization and others outside of medical care with significant morbidity and mortality. [For more on abortion prior to Roe, see Taussig (1936) and Calderone (1958).] Roe authorized abortion beyond the point of fetal viability to protect the “life or health” of the mother. Doe provided such a broad definition of “health” that it effectively required that there be abortion-on-demand through a pregnancy’s entirety.[4] Thus, the Supreme Court’s abortion decisions imposed on the United States one of the most permissive abortion law regimes in the world.
The discounting of women’s needs is present in Dr. Davenport’s use of the term health just as it was when John McCain used air quotes around “health” during the 2008 presidential debate. The implication is that women can get an abortion for any reason and that somehow that has to be stopped. Women deserve much more respect in their decision making. Abortion later in pregnancy is not something women perform on a whim. The social construction of the teenager who gets an abortion to fit into her prom dress just doesn’t pan out in reality. Rather, teens without access to support around their pregnancies also deliver those babies in a bathroom, take drugs to induce their pregnancies, or ask their partners to beat them in the stomach with a baseball bat (all events that have been reported in the news in the last few years). The permissiveness of the law has not led to a high use of abortion in later pregnancy. As Dr. Davenport notes above, only 1.3 percent of all abortions occur after twenty weeks. Thus, despite the legal right to abortion through viability, the vast majority of abortions occur in the early stages of pregnancy, suggesting that women do not simply wait to have their abortions because the law says they can.
Although the reproductive health pioneer Dr. Elizabeth B. Connell predicted in 1971 that contraception and early abortion would render late-term abortion obsolete, joining “the bubonic plague and poliomyelitis as practically historic conditions,” the proportion of late-term abortions has varied little in the last two decades. It is too bad that this prediction was ever made. As Dr. Davenport points out, the percentage of abortions occurring later in pregnancy remains constant. This experience is also replicated in Europe. What we can learn from the consistency of the data is that abortion is an inevitable part of the course of human reproduction. The cautious tale to those who seek “common ground” by eliminating the need for abortion is that abortions will always be needed: Life is complicated, humans are imperfect, sex has consequences, and medical and life conditions arise even when all the precautions in the world are taken. Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers, shocked the general public in 1997 when he admitted that the vast majority of partial-birth abortions were performed on healthy mothers and babies.[5]
Fitzsimmons should not have spoken about things he did not fully understand, and it is regrettable that his comments still haunt the discussion today. He is neither an expert in data nor a physician who performs the technique often referred to as “partial-birth abortion,” intact dilation and extraction, or intact dilation and evacuation. Contrary to the assertion of abortion rights supporters that late-term abortion is performed for serious reasons, surveys of late abortion patients confirm that the vast majority occur because of delay in diagnosis of pregnancy.[6] They are done for similar reasons as early abortions: relationship problems, young or old maternal age, education or financial concerns.[7]
The advocacy claim that abortions after the point of expected viability are for serious reasons cannot be answered with the data used by Dr. Davenport in her argument. Both the studies that Hammond discusses in his review and the Finer et al. study are studying second-trimester abortions as a whole and not abortions in later pregnancy. As Dr. Davenport notes above, only 1.3 percent of abortions occur after twenty weeks, while 10.7 percent occur between thirteen and twenty weeks. These studies tell us nothing about why women who had later abortions at Dr. Tiller’s practice had those procedures. The lack of clear definitions means we do not know the number of abortions for each of the three categories included in “abortions later in pregnancy,” nor do we know the reasons women have these abortions. Such an absence of information should make the reader question accepting the blanket claim that “late-term abortion is never necessary.”
Most of Tiller’s abortions conformed to the generally elective character of these late-term procedures. Peggy Jarman of the Pro-Choice Action League stated that about three-fourths of Tiller’s late-term patients were teenagers who denied to themselves or their families that they were pregnant until that fact could no longer be obscured.[8] This information is very old—1991. Then-Kansas Attorney General Phill Kline initiated a review of Tiller’s records of late-term abortions.
Dr. Tiller was acquitted of these charges. One of the nation’s most distinguished psychiatrists, Dr. Paul R. McHugh, Johns Hopkins professor of psychiatry, was asked to determine if Tiller’s patients satisfied Kansas requirement that they were likely to suffer a substantial and irreversible impairment if not allowed to abort. Dr. McHugh reviewed Tiller patient records and determined that they were not.[9]
Fortunately for Dr. Tiller and his patients, this is only one expert’s opinion. Dr. McHugh never saw the patients, nor was his opinion influential in the latest decision acquitting Dr. Tiller of violating the law in Kansas regarding mental health. Three decades of advocacy for women’s health point to the importance of taking women’s mental health concerns seriously (DHHS, 2009) and not privilege the opinion of one “expert” over the opinion of her consulting physicians and the patient herself.
Although most late-term abortions are elective Technically, all abortions are “elective,” as no woman undergoes an abortion against her wishes. I believe Dr. Davenport means that most abortions later in pregnancy are for non-medical reasons or fetal indications. Again, whether she is including abortions before viability is unclear here. I look forward to her clarification on this issue.
Although the best data on both early and late second trimester abortions is imperfect, the information from the CDC, Guttmacher Institute, and Hammond’s 2009 study on second trimester abortion support the contention that the vast majority of these abortions are not for serious maternal medical indications. , it is claimed that serious maternal health problems require abortions. Intentional abortion for maternal health, particularly after viability, is one of the great deceptions used to justify all abortion. The very fact that the baby of an ill mother is viable raises the question of why, indeed, it is necessary to perform an abortion to end the pregnancy. With any serious maternal health problem, termination of pregnancy can be accomplished by inducing labor or performing a caesarean section, saving both mother and baby. If a mother needs radiation or chemotherapy for cancer, the mother’s treatment can be postponed until viability, or regimens can be selected that will be better tolerated by the unborn baby. In modern neonatal intensive care units, 90 percent of babies at 28 weeks survive, as do a significant percentage of those at earlier gestations.
There are several problems with this argument. It fails to address the significant complications and costs of fetuses delivered before twenty-eight weeks [see Kilpatrick et al. (1997)]. Additionally, it conflates “survival” with being a healthy baby. Many neurological and developmental complications result from early delivery and technical “survival.” The importance of high quality and accessible neonatal care for women desiring to continue their pregnancies cannot be ignored. But that is radically different from asserting that we as a society are better off with more early deliveries performed against a woman’s desire to discontinue that pregnancy.
T. Murphy Goodwin, M.D., a distinguished professor of maternal-fetal medicine at the University of Southern California, has written an eloquent article describing how women are told they need abortions for their own health when this is patently untrue.[10] A major reason for unnecessary abortion referrals is ignorance, to put it bluntly, especially on the part of physicians in medical specialties inexperienced in treating women with high-risk pregnancies. According to Goodwin, there are only three very rare conditions that result in a maternal mortality greater than 20 percent in the setting of late pregnancy.[11] Even in these three situations, there is room for latitude in waiting for fetal viability if the mother chooses to accept that risk. Dr. Davenport’s inclusion of this information is appreciated. I believe this is where common ground could be found. Women with medical complications who desire to continue their pregnancies should have access to and support in locating health care services just as those who do not want to continue their pregnancies need accessible health care. As Dr. Davenport points out, women have the right to assume risks to their health to continue their pregnancies. If women are being forced to have abortions out of ignorance on the part of their health care providers, then educational interventions are needed. The solution is not to vilify Dr. Tiller’s practice or make claims that later abortions are never necessary. Instead, we can hold onto both the need for abortion later in pregnancy and the need to care for women who want to continue their pregnancies. The shared value is reflected in Dr. Tiller’s motto: “Trust women.”
Goodwin’s essay presents several cases in which pregnant women with cardiac conditions, cancer, or severe renal and autoimmune disease have been told categorically that they “needed” an abortion for their health or to save their life. But in every case, the women were given wrong diagnoses or incomplete information and not offered any alternatives other than abortion. One example was a 38-year-old woman, 11 weeks pregnant, with breast cancer that had spread to the lymph nodes. She was told that chemotherapy offered her the best chance for survival, that she needed to abort her pregnancy prior to treatment, and that her prognosis was worse if she remained pregnant. Goodwin states: We discussed with her published evidence that breast cancer is not affected by pregnancy and that the chemotherapy regimen required for her condition is apparently well-tolerated by the fetus. The experience with any given chemotherapy regimen is limited, and we were frank with the patient that there were open questions about long-term effects. When her physician was informed of the patient’s desire to undergo chemotherapy and continue the pregnancy, he suggested that we take care of her and accept the liability. The patient underwent chemotherapy (Adriamycin and Cytoxan) and delivered a baby boy who appeared entirely normal at birth. That many chemotherapy regimens can be continued without apparent ill-effect in pregnancy is information readily available to any interested physician, but the patient was not informed. In the prior case, the reluctance of the woman’s physician to treat her was caused by a fear of being sued for unforeseen complications in the baby. An unfortunate reality is that the legal burden for the physician is severe if all possible risks of continuing the pregnancy are not communicated to the patient. In the U.S., multi-million dollar court judgments for “wrongful life” are allowed if the patients assert that they would have had an abortion had they known a particular problem might have ensued. It is impossible to foresee and enumerate each and every possible complication. But if abortion is recommended, even with minimal or no justification, there is no legal penalty. Many women are thus not advised of all the possibilities for treatment and referred for abortion unnecessarily. A good source of information to counter the pro-abortion bias among physicians in these difficult situations is consultation with a pro-life maternal fetal medicine specialist.[12] This resource should be available alongside a listing of physicians who will perform abortions for women unwilling to assume the additional medical risks. The concept behind “pro-choice” is often lost in the highly polemic abortion war, but it is about full and accurate information. Women, not any individual doctor, should determine the course of their pregnancies.
Fetal problems are the other serious rationale for considering abortion, and diagnosis of these abnormalities has multiplied with the increased use of ultrasound in pregnancy. Ultrasound studies of fetal anatomy are often done at 18–20 weeks, so abortions done as a result of these scans are late abortions. But ultrasound is imperfect, and analysis of the images can result in inaccurate interpretations. All medical tests have inaccuracies. To suggest that all or even most diagnoses are likely to be inaccurate is misleading. Women should be given full information about the sensitivity and specificity of tests. They also need information about access to abortion should they decide to discontinue their pregnancies based on their understanding of the results. The information should not be manipulated on either side. In addition, greater access to health care and education for children with disabilities is needed to support women who carry their pregnancies to term. Pregnant women who have declined abortion for fetuses diagnosed by ultrasound with fatal birth defects such as Potter’s syndrome (kidney disease with no amniotic fluid) or thanatophoric dwarfism (a fatal form of skeletal disease), have sometimes ended up giving birth to normal babies. Other parents have resisted recommended abortions for serious anatomical problems such as prune belly syndrome, omphalocele, congenital absence of the diaphragm, and other severe birth defects and had their babies undergo surgical repair after birth. C. Everett Koop, M.D., the former surgeon general and renowned pediatric surgeon, was asked during the partial-birth abortion hearings if he had treated children “born with organs outside of their bodies” (omphalocele). Dr. Koop replied, “Oh, yes indeed. I’ve done that many times. The prognosis usually is good. … The first child I ever did, with a huge omphalocele much bigger than her head, went on to develop well and become the head nurse in my intensive care unit many years later.”[13]
For fatal birth defects, abortion is sometimes presented as the only option. But a better alternative is perinatal hospice. Perinatal hospice is an important option, but it is paternalistic to claim it as the “better alternative.” Women should be allowed to make decisions based on their personal belief systems and not be forced into the choice that Dr. Davenport finds more acceptable given her beliefs. The Santorums had every right to their decision and should be supported in making it. This involves continuing the pregnancy until labor begins and giving birth normally in a setting of comfort and support until natural death occurs. It is similar to what is done for families with terminally ill children and adults. Karen Santorum, a nurse and the wife of former Senator Rick Santorum, was faced with the prospect of her own son, Gabriel, being born with a fatal birth defect. She describes how Gabriel lived only two hours but how in those two hours “we experienced a lifetime of emotions. Love, sorrow, regret, joy—all were packed into that brief span. To have rejected that experience would have been to reject life itself.” The sense of peace and closure felt by families experiencing neonatal death in a hospice setting contrasts markedly with the experience of families undergoing abortion for fetal anomalies. Many couples who have had abortions for birth defects suffer from adverse long-term psychological effects and prolonged grief reactions.[14] Children who learn that their mothers aborted their siblings can suffer feelings of worthlessness, guilt, distrust and rage.[15]
Non-fatal birth defects can be more challenging. The most common prenatal diagnosis resulting in mid-trimester abortion is Down syndrome. There has been an aggressive campaign by the American College of Obstetrics and Gynecology to use new technologies to detect Down syndrome in younger women through measurement of fetal neck-fold thickness and first trimester blood tests now that prenatal diagnosis and abortion have succeeded in eliminating 90 percent of Down babies in women over 35. After diagnosis of Down syndrome, families are often not presented with an honest discussion of parenting their Down syndrome child or the possibility of their Down syndrome child attending school and leading a semi-independent life. There are couples who are willing to adopt children with Down syndrome or other birth defects, but genetic counselors frequently do not give patients this information. Dr. Davenport is very sensitive to the psychological trauma associated with losing a child, but she fails to acknowledge that adoption is not without significant psychological challenges for some women. While it is an important option for some women, it cannot be thought of as a panacea for the need for abortion. Diagnosis of a child with a fetal anomaly is life-changing and a major stress, but many families rise to the occasion and are able to cope with a disabled child. Although parents choosing abortion may allege that the disabled child is better off not existing, disabled adults would contest that assertion. When surveyed in numerous studies, no differences have been found between disabled and “able-bodied” people as to their satisfaction with life.
The Tiller murder, as well as the legislative and judicial hearings on partial-birth abortion, have exposed the public to a repugnant discussion of late-term abortion techniques, which include fetal dismemberment, partial-birth abortion, and feticidal injection of digoxin or potassium chloride into the unborn baby’s heart preceding multi-day induction of labor.[16] The decision about which medical interventions to support is never made based on the aesthetic nature of that care. Rather, the Institute of Medicine (IOM) suggests two criteria for assessing quality care: (1) the level of scientific evidence supporting that care and (2) the individualized needs and preferences of the patient (see IOM 2001). Abortions later in pregnancy are socially and medically complicated. They should not be further politicized by arguments that ignore the lived experiences of women who obtain care and the physicians who risk their lives to provide that care.
The repugnance of late-term abortion techniques is not just about aesthetics. These procedures are abhorrent because they are ethically reprehensible. Concern about fetal pain is also a consideration. Post-viable fetuses are extremely sensitive, as attested to by their gentle handling in neonatal intensive care units. Two inaccurate literature searches by an ACLU lawyer and a psychologist/abortion activist have been published in the medical literature, but they do not negate the latest neurobiological evidence on the neurological capacity and pain perception of human beings twenty-two to twenty-eight weeks gestation, unborn or born. Note the reference below on fetal pain. It is the barbarity of killing a developed, sentient human being, especially with techniques that are painful, that is one of the most morally reprehensible aspects of late abortion.
Davenport’s reference on fetal pain is an article that she herself wrote for a non-peer reviewed publication. She disparages existing literature as being by an “ACLU lawyer “and an “abortion activist.” However, the most recent science on this issue in the peer-reviewed literature is a systematic review published in the Journal of the American Medical Association in 2005 (Lee, Ralston, Drey, Partridge, and Rosen, 2005). The authors of this article include a neonatologist who cares for extremely premature neonates and an anesthesiologist who provides care to women undergoing fetal surgery. They conclude that fetuses do not feel pain until after the twenty-ninth week of pregnancy. Late-term abortions result in more hemorrhage, lacerations and uterine perforations than early abortions,[17]
It is disingenuous to compare the complications of later abortion to those of earlier abortion. No one chooses between the two. Women choose between abortion at the stage of pregnancy they are in and delivery. Abortion, even in later pregnancy, carries less medical risks than continuing a pregnancy to term (Bartlett et al, 2004). as well as risk of maternal death approaching that of carrying the baby to term.[18] Subsequent pregnancies are at greater risk for loss or premature delivery due to trauma from late-term abortions.[19]
This conclusion overstates the results of this study, which does not make a claim about risks from induced abortion at specific gestations. Research efforts to study this connection are complicated by several methodological limitations, including recall bias (women with complications in future pregnancies are more likely to report prior abortions), reasons for the prior abortion (women who have abortions later in pregnancy because they are in the process of losing that pregnancy may be at future risk of an early delivery), technique used for abortion (previously instillation, now dilation and evacuation), and incorrect comparison groups (women with their first delivery and those with multiple prior deliveries). A few studies with greater scientific credibility show no effect of induced abortion on early or later preterm delivery of low birth weight (Raatikainen, Heiskanen, and Heinonen, 2006; Zhou, Sorensen, and Olsen, 1999, 2000). Abortion in later pregnancy is very safe, and abortion techniques continue to advance to make abortion even safer [see Paul et al. (2009)]. Even if small risks did exist, they would be arguments for improved counseling for women, not reasons to deny women abortions.
Weitz is wrong. Eighteen statistically significant studies support the abortion preterm birth link. The latest, a 2009 meta-analysis by Swingle of twelve studies finds a 25 percent increase after one abortion and a 64 percent increase after two or more abortions. It is a disgrace that the abortion-preterm birth link is ignored in the U.S. because of politics. The MOSAIC study cited previously is a large European prospective cohort study from ten countries that is not subject to recall bias. Weitz has apparently not read the Zhou and Sorenson studies that she cites, which state in the conclusion of the 1999 study that preterm birth is doubled after one to two abortions and almost tripled after three. The Zhou study is done from a registry in the Danish national health system, which is not subject to recall bias. Even the Raatikainen study found 7.0 percent preterm birth versus 4.7 percent after two abortions, although the authors attempt to explain the results away through statistical manipulations.
To specifically address Davenport’s charge that I have not read the studies: She is simply wrong. This literature is wrought with problems. In general, most of the studies included in the Swingle et al (2009) meta-analysis fail to control for confounders. Zhou et al (2000) explain the implication of this for their results: “Our study did not show any strong association between induced abortion and low birthweight and it is possible that the association observed is due to confounding.” Most importantly, these studies lack specific attention to the method of abortion used. Methods of abortion have improved significantly in recent years, and these new methods need to be studied specifically to help answer this question. Shah et al (2009) in their meta-analysis explain: “Further studies are needed to assess the impact of newer techniques, to identify the safest method of pregnancy termination in the first and second trimester, or adverse outcomes in subsequent pregnancies.” Any association discovered between abortion and early delivery should lead us to higher quality research and improvements in abortion techniques, not further restrictions on abortion provision. The psychological damage of aborting a late-term pregnancy, particularly one that is desired, can be profound and long lasting.
There is no evidence for this claim. What we know is that wanted pregnancies that do not result in a healthy baby are painful for some women. It is not how the pregnancy is resolved—abortion or carrying to term—that is the cause of the sadness.
On the contrary, a number of studies have shown that late abortions have a significant adverse psychological impact for many women and families. This is especially true for abortions for birth defects, which causes lasting psychological disability in 20–25 percent of women. The literature substantiates that later abortions have more severe sequelae. Some studies attesting to this are listed below. Hospitals set up therapy groups for these post-abortal women for this very reason.
Davenport simply misreads this literature. None of the authors from the cited articles are arguing that women would be spared their grief if they choose to continue their pregnancy to term rather than have an abortion. Kersting et al (2007) explain it clearly: “Overall, our results showed that the majority of women adapt well to a [termination of pregnancy].” In the Korenromp et al (2009) study, less than 3 percent of women indicate that they regretted their decision to terminate their pregnancy. Women’s grief is real and should be addressed with appropriate services, not further vilification of abortion. In fact, White-van Hourik (1992) notes that silence is an important contributor to poor coping and that couples need validation for their decision, not reduced access to abortion. One of the true tragedies in the loss of Dr. Tiller was the closure of his unique emotional support services for women undergoing abortions in the third trimester. His practice was renowned for the amount of psychological support that women and their partners received around the abortion. Health care coverage should be expanded to cover these types of additional services rather than further restricting access to later abortion, as Dr. Davenport is arguing.
In conclusion, although serious threats to health can occur, there is always a life-affirming way to care for mother and baby, no matter how bleak the prognosis. I am most troubled by this paragraph and the use of the term always. There are no absolutes in medicine, and to suggest there are makes me believe the author is more interested in the political rather than scientific debate. What Dr. Davenport has successfully managed to do in this article is expand our understanding of the needs of women who do not want abortion as the treatment for their health or social condition. To layer this understanding onto all the women who received care from Dr. Tiller is concerning. The elimination of abortions prior to viability would mean that many women would be forced to continue pregnancies to term against their will. Arguing that all women who want abortions after viability to protect their health should be forced to assume the additional medical risks is equally problematic. And finally, how women choose to deal with a pregnancy should not be made for her but rather by her with full information and support. The elimination of late-term abortion would not create a void in medical care but would instead result in a more humane world in which vulnerable humans would be treated with the dignity and respect that they deserve.
I believe that women, not just the fetuses they are carrying, deserve the same level of compassion and to be treated with dignity and respect. The many women who obtained abortions later in pregnancy from Dr. Tiller are our sisters, our friends, and our neighbors. They made decisions based on the best medical evidence presented to them by their health care providers and community and what they knew about themselves and their families. Because pregnancies, like life, do not always progress as we would like, women will continue to make decisions to have abortions. What women lost in Dr. Tiller’s killing was access to a physician who was willing to trust their decision making and make himself well enough known so that women, and the man who eventually killed him, could find him. To argue that abortions later in pregnancy are never needed is to ignore the lived experiences of real women and to simplify complicated medical issues in the name of a political agenda to make abortion illegal.
Weitz states that women, not just the fetuses, deserve compassion and to be treated with dignity and respect. I believe this also. However, there is no way to reconcile the principle of dignity and respect for the unborn with killing them. To assert this is a convolution of logic. The fact that some medical organizations and physicians endorse intentional abortion does not mean that it is morally defensible or medically necessary. Nazi physicians executed disabled and “socially undesirable” fetuses and infants because of a disordered ideology. Weitz elevates the desires of women and bodily autonomy to a level higher than any other ethical principle, an equally disordered social ideology. A woman’s wishes and bodily autonomy are very important values, but they should not be regarded more highly than maternal or fetal life itself.
It is clear from this answer that Davenport believes all abortions are wrong, not simply abortions on potentially viable fetuses. From her perspective, to allow women the option to terminate a pregnancy at any time is an ethical violation. This is our fundamental disagreement. She believes abortion at any time represents disordered ideology and equates the women who choose to have abortions with Nazis. I believe such extremism is dangerous and results in the kind of violence that took Dr. Tiller’s life. I believe that women can make reasoned ethical decisions in alignment with their own values. There is no convolution of logic: Women’s rights do take preference over the potential life of the developing fetus. This is the core of the Roe v. Wade decision with which Davenport clearly disagrees. I believe that we need a reasoned discussion about the complexity of later abortion and in particular, those that take place after the assumed point of fetal viability. To date, in the United States, those abortions occur when the health of the pregnant woman is in jeopardy, or when there are significant problems with fetal development. These are no whimsical decisions and are imbued with ethical complexity. However, all of us are best served when women and their physicians examine the medical necessity of the need for abortion on a case-by-case basis. Abortions later in pregnancy are sometimes medically necessary. There are no absolutes in medicine or life.
[1] Press release, “NARAL Pro-Choice Colorado Statement on Dr. George Tiller’s Assassination,” (Denver, CO: June 1, 2009). “NARAL” is an acronym for a pro-abortion group founded in 1968. The acronym first stood for “National Association for the Repeal of Abortion Laws,” but after Roe v. Wade was decided in 1973 the name was changed to National Abortion Rights Action League and later to National Abortion and Reproductive Rights Action League. In 2003, the national organization became NARAL Pro-Choice America. [2] There are two organizations reporting abortion statistics in the U.S. The CDC relies on data from state governmental sources but excludes several states that have no reporting requirements. The Guttmacher Institute’s data is collected from abortion providers. The Guttmacher data is more inclusive and accurate for the total number of abortions but lacks the analytical detail of the CDC statistics. It is generally believed that abortions are underreported. [3] The Guttmacher statistics for 2005 are published in R.K. Jones, M.R. Zolna, S.K. Henshaw, and L.B. Finer. “Abortion in the United States: Incidence and Access to Services, 2005.” Perspectives on Sexual and Reproductive Health 40 (Mar 2008): 6-16. The CDC data can be found in Sonya B. Gamble, Lilo T. Strauss, Wilda Y. Parker, Douglas A. Cook, Suzanne B. Zane, and Saeed Hamdan. “Abortion Surveillance—United States, 2005,” MMWR Surveillance Summaries 57 (SS-13) (Atlanta, Ga: Centers for Disease Control and Prevention, Dep’t of Health and Human Services, Nov. 28, 2008): 1-36 (Tables 1, 6). [4] Americans United for Life. Defending Life 2009: Proven Strategies for a Pro-Life America (Chicago, IL: AUL Legal Guide 2009): 55. Go to: http://dl.aul.org [5] Wikipedia, Ronald J. Fitzsimmons. The Wikipedia entry contains a link to this article (.pdf): Diane M. Gianelli. “Medicine Adds to Debate on Late-term Abortion: Abortion Rights Leader Urges End to ‘Half Truths,’” 40 American Medical News (Washington, D.C.: American Medical Association), March 3, 1997. [6] Cassing Hammond, “Recent Advances in Second Trimester Abortion: An Evidenced-based Review” American Journal of Obstetrics and Gynecology, 200 (April 2009): 347–356. [7] Lawrence B. Finer, Lori F. Frowth, Lindsay A. Dauphinee, Susheela Singh, and Ann M. Moore, “Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives.” Perspectives on Sexual and Reproductive Health, 37 (Sept. 2005): 110–118. [8] Alan Bavley. “Abortions Late in Pregnancy Push Public, Doctors to Moral Dilemma.” Kansas City Star (Aug. 26, 1991): B1. [9] Bill O’Reilly. “The O’Reilly Factor,” Fox News Channel, June 13, 2007 (interview with Paul McHugh, M.D.) (< http://www.foxnews.com/story/0,2933,281861,00.html >). Dr. Paul R. McHugh, M.D., is the University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine, and he is currently a member of the President’s Council on Bioethics. [10] T. Murphy Goodwin. “Medicalizing Abortion Decisions.” First Things, 61 (March 1996): 33–36. [11] The conditions are Marfan’s syndrome with aortic root involvement, complicated coarctation of the aorta, and, possibly, peripartum cardiomyopathy with residual dysfunction. [12] A directory of pro-life maternal-fetal medicine specialists can be found on-line. Go to: <www.prolifemfm.org>. These superbly qualified physicians are eager to help women who have been advised to undergo an abortion for medical reasons or fetal birth defects. [13] Text from Congressional Record, Senator Rick Santorum, September 24, 1996. Santorum included the following article for the record: Diane Gianelli and Christina Kent. “The View From Mount Koop,” American Medical News (Washington, D.C.: American Medical Association), Aug. 19, 1996. Link to C-SPAN “Congressional Chronicle”: http://bit.ly/X4lXz [14] M. C. White-van Mourik, J. M. Connor, and M. A. Ferguson-Smith. “The Psychosocial Sequelae of a Second-trimester Termination of Pregnancy for Fetal Abnormality.” Prenat Diagn. 12 (Mar 1992): 189–204. [15] P.G. Ney. “Post-abortion Survivors Syndrome.” Can J Psychiatry 38 (Oct 1993): 577–8. [16] Cathy Cleaver Ruse and William L. Saunders, Jr., “Partial-Birth Abortion on Trial” (Washington, D.C.: Family Research Council, 2006). Ruse and Saunders present sworn federal testimony by those who performed partial-birth abortions. The technical medical term for dismemberment abortion is “dilation and evacuation”; for partial-birth abortion it is “intact dilation and evacuation.” [17] Daniel Grossman, Kelly Blanchard, and Paul Blumenthal. “Complications after Second Trimester Surgical and Medical Abortion.” Reproductive Health Matters Supplement 16 (May 2008): 173–82. Abstract available at SSRN: http://ssrn.com/abstract=1350296 [18] A study by the Centers for Disease Control showed abortion mortality rises sharply with each week of gestation. In the study period 1988–1997 the mortality rate for induced abortion after 20 weeks was 8.9 per 100,000. The maternal mortality rate for live birth in a comparable period was 7.06. See L. A. Bartlett, C. J. Berg, H. B. Shulman, S. B. Zane, C. A. Green, S. Whitehead, H. K. Atrash. “Risk Factors for Legal Induced Abortion-related Mortality in the United States.” Obstet Gynecol. 103 (Apr 2004): 729–37; D. A. Grimes. “Estimation of Pregnancy-related Mortality Risk by Pregnancy Outcome, United States, 1991 to 1999.” Am J Obstet Gynecol. 194 (Jan. 2006): 92–4. Since 2000 maternal mortality for live births in the U.S. has risen to 13 in 2004 (CDC). Weitz references American College of Obstetricians and Gynecologists. 2002. Diagnosis and management of preeclampsia and eclampsia. Obstet Gynecol 99(1): 159–67. American College of Obstetricians and Gynecologists. 2007. Premature rupture of membranes: Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol 109(4): 1007–19. Bartlett, L. A., Berg, C. J., Shulman, H. B., Zane, S. B., Green, C. A., Whitehead, S. et al. 2004. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 103(4): 729–37. Boonstra, H. D., R. B. Gold, C. L. Richards, and L. B. Finer. 2006. Abortion in women’s lives New York, N.Y.: Guttmacher Institute. Calderone, M. S., ed. 1958. Abortion in the United States. New York, N.Y.: Hoeber-Harper. Condit, C. M. 1990. Decoding abortion rhetoric: Communicating social change. Urbana, Ill.: University of Illinois Press. Department of Health and Human Services (DHHS). 2009. Action steps for improving women’s mental health. Washington, D.C.: Office on Women’s Health, U.S. Department of Health and Human Services. Freedman, L. R., U. Landy, and J. Steinauer. 2008. When there’s a heartbeat: miscarriage management in Catholic-owned hospitals. Am J Public Health 98(10): 1774–78. Grimes, D. A. 1998. The continuing need for late abortions. Journal of the American Medical Association 280(8): 747–50. Institute of Medicine (IOM). 2001. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press. Joffe, C. 1995. Doctors of conscience: The struggle to provide abortion before and after Roe v. Wade. Boston: Beacon Press. Jones, B. S., and T. A. Weitz. 2009. Legal barriers to second-trimester abortion provision and public health consequences. Am J Public Health 99(4): 623–30. Kilpatrick, S. J., M. A. Schlueter, R. Piecuch, C. H. Leonard, M. Rogido, and A. Sola. 1997. Outcome of infants born at 24–26 weeks’ gestation: I. Survival and cost. Obstet Gynecol 90(5): 803–8. McHugh, P. 2004. Surgical sex. First Things 147 (November). Morgen, S. 2002. Into our own hands: The women’s health movement in the United States, 1969–1990. New Brunswick, N.J.: Rutgers University Press. Paul, M., E. S. Lichtenberg, L. Borgatta, D. A. Grimes, P. G. Stubblefield, and M. D. Creinin, eds. 2009. Management of unintended and abnormal pregnancy: Comprehensive abortion care. West Sussex, U.K.: Blackwell Publishing, Ltd. Raatikainen, K., N. Heiskanen, and S. Heinonen. 2006. Induced abortion: Not an independent risk factor for pregnancy outcome, but a challenge for health counseling. Annals of Epidemiology 16(8): 587–92. Taussig, F. J. 1936. Abortion spontaneous and induced: Medical and social aspects. St. Louis, Mo.: Mosby. Weisman, C. S. 1998. Women’s health care: Activist traditions and institutional change. Baltimore: Johns Hopkins University Press. Weitz, T. A., and S. Yanow. 2008. Implications of the federal abortion ban for women’s health in the United States. Reprod Health Matters 16(31 Suppl.): 99–107. Zampas, C., and J. M. Gher. 2008. Abortion as a Human Right: International and regional standards. Human Rights Law Review 8(2): 249–294. Zhou, W., H. T. Sorensen, and J. Olsen. 1999. Induced abortion and subsequent pregnancy duration. Obstet Gynecol 94(6): 948–53. Zhou, W., H. T. Sorensen, and J. Olsen. 2000. Induced abortion and low birthweight in the following pregnancy. Int J Epidemiol 29(1): 100–6. Dr. Weitz would like to thank Jennifer Kerns, M.D., M.P.H., for her assistance in writing her responses. |
