The third and final Presidential debate focused very quickly on abortion. Clinton defended choice and Trump, not one to be bothered with facts, countered with this doozy of line:
“I think it’s terrible if you go with what Hillary is saying in the ninth month you can take the baby and rip the baby out of the womb of the mother just prior to the birth of the baby. Now, you can say that that’s okay, and Hillary can say that that’s okay, but it’s not okay with me. Because based on what she’s saying and based on where she’s going and where she’s been, you can take the baby and rip the baby out of the womb in the ninth month, on the final day. And that’s not acceptable.”
First of all, we don’t rip anything in OB/GYN. In surgery we use sharp dissection and blunt dissection, but we don’t rip. Some women do tear during a vaginal delivery, but that’s not a doctor ripping the baby out. Even with a forceps delivery I wouldn’t call it ripping. We also don’t rip tissues during c-sections. Perhaps we can forgive Donald Trump for not knowing this as it is hard to believe that a man who bragged that he doesn’t change diapers and said he wouldn’t have had a baby if his wife had wanted him to actually physically participate in its care would have attended the birth of his own children. It’s certainly not for the faint of heart as there is, after all, lots of blood coming out the “wherever.”
Trump’s statement, as incorrect as it may be, supports the fallacy of the due-date abortion. It is a common anti-choice narrative that women come in at 39 weeks and have some kind of abortion for fun or out of boredom and that we doctors are only too happy to comply. I’m sure some people think there are Groupons. The more graphic the description of the procedure the better as it helps to distract from the facts.
Talking about abortion from a medical perspective is challenging when you are not a health care provider. Even someone familiar with the laws can get confused. For example, Mrs. Clinton made an error speaking about late-term abortion when she said it was a health of the mother issue. Typically it is not (it’s almost always fetal anomalies). However, this error on Clinton’s part only underscores how important it is for politicians to not practice medicine.
To put it in perspective 1.3% of abortions happen at or after 21 weeks and 80% are for birth defects. Put another way 1% of abortions are after 21 weeks and are for birth defects and 0.3% of abortions are after 21 weeks and are not for birth defects (some of these will be health of the mother and a very few will be for other indications). Let’s take it situation by situation.
Late-term abortion is > 21 weeks
Birth Defects
This could range from Down syndrome to anomalies incompatible with life. The generally accepted limit of viability is 24 weeks so before that gestational age abortions can happen for any reason. After 18 or so weeks the options are an induction of labor or a dilation or an evacuation (or D and E), which is a surgery. With induction it can take a few days as labor can be hard to trigger so early. If all goes well the cervix dilates and the fetus delivers. Sometimes indictions fail because you can’t always get such a premature uterus to contract. With a D and E the cervix is dilated, with the help of medication, instruments or both, and the fetus is removed. The fetus is essentially taken apart with a D and E to fit through the dilated cervix (the cervix is dilated less with a D and E than for an induction). This is no secret to the women having the procedure. This is also no ripping, there is simply surgical technique. Women know they were pregnant before the procedure and that they were not after and trust me they don’t think their doctor waved a magic wand or had a time turner.
After 24 weeks birth defects that lead to abortion are very severe and typically considered incompatible with life. These procedures are either a traditional induction, just like labor, or something that requires instrumentation. Because of the nonsensical partial birth abortion law women who wish to have a dilation and extraction (a modified technique for more advanced procedures) need to have fetal cardiac activity stopped with an injection into the uterus. Either way it’s a 2 or 3 day or even 4 process to get the cervix to dilate enough. The further along in the pregnancy, the more likely the procedure will be an induction of labor, but a skilled practitoner can do a dilation and extraction at 32 or 34 weeks. I’ve never heard of a dilation and extraction for any other reason than severe birth defects and often it is for a woman who has had two or three c-sections for whom inducing labor might pose other health hazards, like uterine rupture. Are we to force women to have c-sections for a pregnancy that is not compatible with life?
Why do some women end up with these procedures later on in their pregnancy? Sometimes it can take weeks or even longer to fully understand what is going on with the fetus. Some patients might think they can make it to term and then at 34 weeks cave and ask to be delivered because they just can’t bear one more person asking them about their baby. Do they just smile and walk away or say, “Well, actually, my baby has no brain and will die at birth?” Some women go to term and others can’t. To judge these women for requesting an early delivery is cruel on so many levels. I wrote more about it here if you are interested. Regardless, terminations for birth defects isn’t ripping “the baby out of the womb in the ninth month.” At 38 or 39 weeks it’s always an induction and is simply called a delivery.
Health of the Mother
This definitely happens between 20 and 24 weeks. The most likely scenario is ruptured membranes and an infection in the uterus. The treatment of this is delivery or the infection will spread and kill the mother, however, someone with lupus or renal disease or heart disease (for example) could have a deterioration of their health and with their providers make the decision to have a termination. After 25 weeks this would simply be a c-section or an induction of labor and the baby would go to the neonatal intensive care unit. Between 24-25 weeks there could be some leeway as conditions that are serious enough to require delivery at 24 weeks often also have devastating effects on the fetus. For example, the fetus could be so severely growth restricted making viability at 24 weeks unlikely and a woman with a severe heart condition may not elect to risk her health with a c-section for a likely non viable pregnancy and choose a termination. These are difficult and nuanced decisions and everyone is simply working together to make the best decision for the pregnant person. I don’t know where Mrs. Clinton got this “bad news at the end” of the pregnancy being about maternal health. I have only ever heard of one very late abortion for maternal health and that was for the rape of a minor by her brother and that was still not at term.
So no one is performing health of the mother abortions at 38 or 39 weeks we just do deliveries. It’s called obstetrics.
Other
Some of the 0.3% of abortions after 21 weeks will be for personal reasons. Often these are called elective abortions, but I don’t like that term. Usually this happens when it took too long to find a clinic and raise the money. These abortions happen before 24 weeks. There is no ninth month action here either.
The facts
There are no ninth month abortions. Really. A ninth month abortion is a unicorn and so it’s ridiculous to even discuss it. Terminations after 24 weeks are for severe fetal anomalies.
If it’s a unicorn, why not legislate it? Introducing a gestational age limit is introducing the thin edge of the wedge. Once you say abortion is illegal at say 37 weeks then you have agreed the subject is up for negotiation and more legislation.
If someone were truly interested in reducing abortion they wouldn’t start with the 1.3%, more reductions can be made in the first trimester where most terminations are due to unplanned pregnancies. These abortions could be reduced dramatically with access to free and accessible long-acting reversible contraception. To dismiss these abortions and focus on the later procedures means it is not about reducing abortion at all, so it can only be about punishment and control.
There is no such thing as a ninth month abortion – I’m a doctor who trained in late term abortions #debate2016
— Jennifer Gunter (@DrJenGunter) October 20, 2016
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***Comments are now closed due to an increasing number of abusive remarks***
Dr. Jen Gunter 
Perhaps we need a discussion of spontaneous abortions or miscarriages. Statistics regarding percentage of fetuses that will prove to be viable at conception and at what gestational points the non-viable fetuses will be miscarried.
Thank you so much for writing this up. I have been wondering about such questions all day. Karen Cummings
It’s possible that soon-to-be President Clinton is referring to a mother’s mental health, rather than her physical health. You note yourself that some women elect abortion at that stage because they can no longer mentally cope with the knowledge that their baby will be born dead, with having to endure the comments of well-meaning strangers who should learn to mind their own business. Yes, it will be born dead due to birth defects, but the decision to terminate is due to the mental health of the mother. And if her mental health is severely affected, it could affect her physical health — it could even lead to suicide. So, even if that’s not what she meant, it’s the case.
We learned long ago not to refer to the woman’s mental health when talking to rabid anti-choice people.
Thank you for sharing this information. I have an additional question, just to clarify. When you say that terminating pregnancy after 24 weeks is called induction of labor or a delivery, does that mean that at viability age a surviving fetus will be transferred to the NICU as a preterm baby, as opposed to the fetus dying in a D and E procedure (that is common during week 18-24) to end the pregnancy? I am asking about the scenario in which neither the mother’s nor the fetus’ health is the reason to terminate the pregnancy (even if that may be very rare). In other words, at viability (ca. 24 weeks) a fetus that survives delivery will be treated as a patient, even if the mother does not want to have/parent a baby? Many thanks!
I wish that your article addressed more the difference between disabilities such as Down’s Syndrome and severe malformations that are incompatible with life. All of the mothers I know that have given birth to children with Down’s Syndrome find them a joy, even my friend whose child with DS was also a preemie and also has autism (but most are not that severly disabled). My own experience with my IUGR 27 weeker with a rough NICU experience has been an amazing growing experience and one of the greatest joys and blessings of my life. Another point is that advice given by health care providers regarding likely future of children with disabilities (based on people I know) often reflects the values of the provider, and is often incomplete. I wonder how often there is any information given about support and the positive side of life with a disabled child, or the positive side of challenges.
I’m in medical school now. This article is exactly what I have been trying to communicate to my strictly conservative pro-life friends and family but so much more eloquently articulated than I could have ever attempted to do! THANK YOU!!!
This article is incredibly helpful in breaking down this topic! Thank you.
“First of all, we don’t rip anything in OB/GYN. In surgery we use sharp dissection and blunt dissection, but we don’t rip.”
Uhhh, yeah actually, you do. I’ve had my hand grasped around one side of the abdominal muscles while the surgeon did the same on the other side of the operating table and we both pulled our hardest. That is pretty explicitly “ripping” and it’s the standard procedure.
I’m not defending Trump one single bit but if you are going to pick apart his language be very careful about yours.
And the surgeon dictated it as ripping? Or perhaps to your untrained eye you didn’t understand that traction and blunt dissection can at times require force.
Classic. “Nastygirl,” is complaining about her uncomfortable abortion. Starting to understand why this idiot has supporters.
It’s none of my business what circumstances led you to make the heartbreaking decision to have an abortion, but I just wanted to point out one thing: At some point in your life, you had to make that decision and had the ability to do so.
Can you imagine if you weren’t able to make that choice? That uncomfortable “ripping” would be the least of your worries miss “nastygirl.”
How about amniotic fluid embolism ? If this happens, is it true that sometime you can only keep either mother or infant ?
There is a high maternal mortality with AFE but it does not pose an either/or for mother/fetus
small typo. “only to happy to comply” Too happy.
Thank you doctor for pointing out facts in a clear manner. Hillary was a bit misinformed about some details, and hopefully will read your article. Trump was simply egging on his base and the anti-choice brigade.
Once again thank you. You are a Rockstar!
Thank you for this enlightening article. I’d like to think that a little education would make a difference with the “deplorables” but I won’t hold my breath. Keep up the good work.
Most informative and helpful, thank you.
Excellent article, but how dare you introduce actual facts and medical knowledge into this debate? There’s no place for sanity when debating Trump and his opinions.
So please explain partial birth abortions, which needed an actual ban? (I don’t want a technical response, I know what it is and how it happens.) How does that differ besides that it is really tantamount to killing live human being. If there is a serious reason for a late term abortion, so be it. Mother and/or baby’s health is first, but I cannot wrap my head around partial birth.
I am not sure I understand your dilemma. There is no medical procedure called a partial birth abortion. An intact dilation and extraction is only performed for the health of the mother or for fetal anomalies (birth defects).
You just said a baby is essentially taken apart…and u see nothing wrong with that? Before 24 weeks the heartbeat is not stopped before it is “taken apart” ?
The term is embryo or fetus depending on the gestational age
I believe the math doesn’t work on this phrasing, but I could be wrong. “To put it in perspective 1.3% of abortions happen at or after 21 weeks and [[[80% are for birth defects.]]] Put another way [[[1% of abortions that are at or after 21 weeks and are for birth defects]]] ” It can’t be 80% and 1% at the same time. Maybe you meant to say 1% of all abortions that take place occur after 21 weeks and are for birth defects. Another figure would be x% of all abortions for birth defects take place after 21 weeks.
I think she is saying, “1.3% of abortions happen at or after 21 weeks. Of that 1.3%, 80% of them are for birth defects.”
Jen – This is very helpful. Thank you.
I think the sentence above the pie chart is confusing:
“Put another way 1% of abortions that are at or after 21 weeks and are for birth defects and 0.3% of abortions are at or after 21 weeks and are not for birth defects (some of these will be health of the mother and a very few will be for other indications).”
I think it should read “1% of abortions are at or after 21 weeks and …” I’m sorry to nitpick but I think that changes the meaning of the sentence and I don’t want people to think (or wrongly cite you for the proposition) that only 1% of late term abortions are for fetal anomalies.
Again, thank you for your work and this piece!
Hi Dr. Jen, thanks for this. I have a question about the methods of late term abortion that I’m hoping you can help me with. I had read a post on a friend’s facebook several weeks ago (which I can’t find now, of course) about the irony behind the religious right’s opposition to late term abortions in particular. The post asserted that an amendment was passed by republicans to regulate the methods around late term abortions, where the doctor is required to dissect the fetus in order to remove it. The post then talked about how Governor Mike Pence signed a law requiring women to have fetuses cremated or interred, regardless of gestational age. The post’s point was the layers of cruelty being inflicted on women who have late-term abortions, especially the majority of women who *wanted* their pregnancy, but had to abort it for medical reasons – the religious right made late-term abortion procedures worse than they needed to be, AND they expect women to care for the body of the fetus after it has been mutilated by the abortion procedure. Is this true? Do you have any idea which amendment on late-term abortion procedures they would be referring to? I haven’t been able to find the post again, and all of my attempts to google the information have produced outdated data or severely biased results. Thanks for your help.
This is what the right believes about women though. That we’re so horrible we have late term abortions because they’re fun and cheap and easy and we’re irresponsible sluts who enjoy murdering. Or something. That’s really what this absurd talk is that essentially women are bad people; and it’s horribly disrespectful to women who have had later terminations and have had to face that tragedy. They really honestly think a woman would suddenly in the 9th month decide she didn’t want her pregnancy. Or that she would deliberately wait until month 9 to have a termination instead of doing it in week 5 when it’s much easier and less painful.
Further, how are these really late abortions even happening? Who is paying for them and what doctor would perform an “abortion” on a woman with a WANTED fetus who is in labor? This is really the crazy that the right-wing has embraced. They actually believe women who are in active labor are seeking terminations.
ABSURD.
Trouble is Donny is not worried about facts , he just says anything that will win him votes , even if the facts are completely wrong . And his fans love him for it .
Does anyone believe Trump has compassion for anything living in this world, let alone the unborn? I applaud Hillary’s stand for women’s rights in this matter. Please check out my campaign song that emphasizes the historic aspect of her candidacy. Go to https://www.youtube.com/user/CraigASilver
Oy! You are truly right in saying that “How important it is for politicians to not practice medicine. ”
I’m just shaking my head.