Term and partial birth abortions: the mythical arch-nemeses of the anti-choice movement

There is a lot of discussion this week about abortion due to Donald Trump reinforcing in front of millions of people the false belief that pregnant women are flocking to their OB/GYNS days before their due date to have their healthy fetuses ripped out with partial birth abortions.

Despite multiple articles indicating this couldn’t be further from the truth and courageous women sharing their stories, many still believe Trump’s version. In fact, people write comments or even whole articles on places like LifeNews that say, “I’m a nurse and I’ve seen it on labor and delivery” or “my cousin’s friend hand one.” Sometimes a purple or orange egg tweets to tell me these procedures exist because they saw it on YouTube.

 

In fact, the more I and others provide clear evidence that a “ninth month abortion” is a mythical creature the more people say it exists. The more I say partial-birth abortions are an inexact term rejected by the American Congress of OB/GYN the more the anti-choice movement doubles down. The more women say how these procedures saved their lives or helped them deal the best way they could when faced with a fetus with a severe birth defect, the more the anti-choice movement responds with cruelty. They do this because the anti-choice movement needs “ninth month” and “partial birth abortions” to exist in the false way they have presented them just like religions need demons or a devil. If you have two arch-nemeses (because two is better than one) that you can paint as pure evil and unnecessary then you can dehumanize the women who have them and further drive the false narrative that these procedures exist everywhere and could never be needed.

 

Let’s walk through it step by step so everyone can make decisions based on facts and not mythical demons.

What is a partial birth abortion?

I don’t know and I am trained in later-term abortions (by that I mean procedures after 16-18 weeks). I don’t do them anymore, but I know what I am talking about.

First of all, one can’t be partially born. In obstetrics you are pregnant or you aren’t and you are delivered or you are not. For example there is an obstetrical emergency called shoulder dystocia where the fetal head delivers but the shoulder get stuck. It’s an emergency and if you don’t act appropriately and promptly the outcome can be horrendous. Even in this situation the pregnancy is not delivered until every part is delivered. Using the term partial birth abortion is like saying “cutting out half the guts” when you really mean a hemi-colectomy. The former is a very imprecise and poor descriptor for the latter.

The American Congress of OB/GYNs (ACOG) has taken this term “partial birth abortion” to mean an intact dilation and evacuation without fetal demise before the procedure. Some also call this procedure a dilation and extraction or D & X. It involves delivering the smallest fetal part through the cervix and decompressing the cranium with suction if needed. That may be hard for some to read, but this is surgery. Are images of this procedure graphic? Yes, but all surgical images are graphic. Before you judge the procedure, please read this article in its entirety. If you want to understand more about the procedure as doctors understand it you can read this article and this Committee Opinion from ACOG.

A D & X can be performed safety up to 36 weeks by a trained provider, but procedures after 27-28 weeks are incredibly rare. Remember, only 1.3% of abortions happen after 20 weeks and most of these happen by 24 weeks.

Why do women need an intact dilation and extraction or D & X?

The more advanced the gestational age the greater the risk of maternal trauma with a standard D & E (dilation and evacuation), so a D & X reduces this risk.  The complication rate, even including pregnancies up to 36 weeks, is 0.5-5%. Before you judge the later procedures, please read the entire article. The complication rate for a c-section is 27% and 10% have serious complications. So obviously if a later pregnancy needs to be delivered the D & X is the safest.

Inducing labor for a 2nd or third trimester abortion is also an option for some women, but it actually has a higher complication rate than a surgical abortion (D & E or D & X). According to ACOG, “Compared with D&E, termination by induction with misoprostol is less cost-effective, is associated with a greater risk of complications, such as incomplete abortion, and may be prolonged.”

Some women may choose an induction of labor as they may be personally more comfortable with that technique and an induction may sometimes be more helpful if an autopsy is needed to help understand the birth defects for future pregnancy planning. However, many women end up with inductions because their doctors aren’t skilled to do a D & X and so the legal system has foisted a less safe medical procedure on them.

When might a later term abortion and specifically D & X be indicated?

Anytime a woman after 20 weeks needs to be delivered. Remember, with a D & X the complication rate is 0.5-5% and a c-section has a complication rate of 27% (but complication rates with c-sections rise the more premature the delivery and with maternal health problems, like infection or high blood pressure).

Consider a woman at 35 weeks and her fetus has Potter syndrome. This is typically not compatible with life (basically no kidneys or lungs). She did not want to have a termination and elects to go through with the pregnancy and deliver at term. She is now 35 weeks and her fetus is a transverse lie (meaning it’s laying sideways not head down or bottom down) and so can’t come out vaginally with a normal labor. The doctors can’t even attempt to turn it head down with a procedure called an external cephalic version because with Potter syndrome there is no fluid and without fluid you can’t turn a fetus. Her choices are a c-section or a D & X.

Consider a woman at 29 weeks and her fetus has trisomy 13. She would have terminated earlier before 23 weeks had she known, however, her doctor is very anti-choice (she was unaware of this) and so her genetic ultrasound occurred late at 21 weeks. By the time she had the amniocentesis and got the results she was 23 weeks. She met with several local OB/GYNs and non had the skill set to do a D & E at 23 weeks as none had abortion training in residency. Emotionally she does not feel she can carry the pregnancy to term. Her local options are a hysterotomy at 23 weeks, basically a very premature c-section which often damages the uterus, or wait until she delivers at term. By the time she locates a provider for a D & X and has raised the cash she is 29 weeks.

Consider a woman with mirror syndrome at 28 weeks. Her fetus has severe birth defects including a massive tumor on the lower back. This can only fit vaginally with some kind of instrumentation. The birth defects appear incompatible with life and she had previously met with a neonatal intensive care specialist at 25 weeks and the plan was no resuscitation after delivery. She is now getting sicker by the minute. Her options are a c-section or a D & X.

Consider a woman with a very wanted twin pregnancy from IVF. At 23 1/2 weeks she gets what she thought was the worst imaginable news, one of her twins has died. But then it gets worse. She develops severe preeclampia and needs to be delivered as soon as possible as her remaining wanted pregnancy is killing her. Her choice is a c-section or a D & E/D & X.

Consider a woman with ruptured membranes at 22 weeks in her first pregnancy. She has an infection and is rapidly getting sicker. She needs to be delivered as soon as possible. Drugs to induce labor have failed as an infected uterus often cannot be flogged chemically into contracting. Her option is a hysterotomy (the early, uterus-damaging c-section) with an infected uterus (her risk of a hysterectomy are high) or a D & E/D & X, which is more likely to save her uterus.

Pregnancy can lead to medically unbelievable scenarios

It is not possible to explain all the permutations and combinations of obstetrical tragedies. The collision of fetal chromosomes and the crazy adaptations that a pregnant woman goes through can lead to some truly medically bizarre and scary situations. Just think about the immune system. Pregnancy is like an organ transplant, except the genetic match is only 50%. To stop the body from attacking or rejecting the fetus the maternal immune system undergoes major changes. It’s not a perfect work around, but evolutionarily speaking it works most of the time. If you are not in the most group then things can go really, really wrong. Like catastrophically wrong. It’s even hard for doctors to understand what can happen. When I explained mirror syndrome to a general surgeon all he could say was, “That’s just messed up.”

As an OB/GYN I can come up with hundreds of scenarios where a D & X is the medically preferred procedure. Everything I think something is just too catastrophic to happen, the human body surprises me. With the “Partial Birth” abortion ban the government took the safest medical option off the table in most states. According to ACOG “the safety advantages of intact dilatation and evacuation (intact D&E) procedures are widely recognized—in medical texts, peer-reviewed studies, clinical practice, and in mainstream, medical care in the United States.”

The ninth month myth

I’ve summarized this elsewhere, but suffice it to say that later procedures – after 23 weeks – happen because of A) maternal health issues like the ones I’ve described above B) fetal anomalies as described above or C) both. There is zero evidence that fetuses who are “perfect” or those with minor abnormalities, like a cleft lip, are being aborted at 24 weeks never mind close to the due date. Data aside let’s just use logic. There are very few providers in the country who can do a D & X over 24 weeks and most only take cash. Insurance companies don’t cover late-term abortions unless there is a health of the mother situation or a serious genetic issue. The providers with the skill to do these procedures generally only take cash, that’s around $15,000 at 24 weeks and by 32 weeks it’s $25,000. And no that’s not what the doctor is pocketing, that money goes to anesthesia, medications, the operating room time, maintaining an ultrasound machine and other equipment, building upkeep, the nurses, the office staff and THEN the doctor. How many women do anti-choice activists really believe are wandering into doctor’s offices with a spare $25,000 for a spur of the moment abortion?

What about Gosnell?

The tragedy of Kermit Gosnell is often thrown about by anti-choice activists, but even he didn’t do “term” abortions. He was convicted or providing grossly negligent care to many women seeking abortion culminating in the death of at least one. It’s a medical horror story. Looking at pictures of his clinic I can only assume that was where a woman went if she were desperate, medically disadvantaged, had very little money, or was unaware of what a safe American medical office might look like. TRAP (targeted regulation of abortion providers) laws drive up the cost of high-quality care forcing the desperate to turn to cheaper options and charlatans like Gosnell. More laws won’t protect women from Gosnell, they will likely drive more women to people like him.

There will always be unscrupulous people and unsafe medical care for profit; this is not an abortion-exclusive phenomenon. There was a dental shop of horrors in Oklahoma where the instruments were not sterilized, an endoscopy clinic in Las Vegas that re-used medical vials exposing patients to hepatitis C and one man died from the hepatitis C he contracted, and lots of counterfeit Botox just to name a few. If we have to make abortion illegal to protect women from people like Gosnell, then using that same logic we should make dentistry and endoscopy and Botox illegal to protect the public as well.

I agree that we need to focus more on the Gosnell case, but not because he provided abortions. We need to talk about this case because it highlights how atrocious care disproportionately affects the desperate and disadvantaged. We must not forget that in America women who seek abortion will almost always be the most disadvantaged of all.

Showing the arch-nemeses for what they are, myths 

The myth of “ninth month” abortions and partial birth abortions accomplish two goals, firing up the base for fund-raising and getting more people to believe that at least some abortion restrictions are needed. Getting 100% of people to align with you on one small part of the procedure makes it easier to gradually push the bar. It is the thin edge of the wedge.

The anti-choice movement needs the idea of partial birth abortions of a healthy fetus in the “ninth month” just like they need the devil. However, if you pull back the curtain on their side-show all you see are women in medically desperate situations in need of high quality medical care.