Late-term Abortion

IN RECENT years, public debate on abortion has focused on surgical procedures used to induce abortion during the second and third trimesters. This was most clearly demonstrated through proposed federal legislation on so-called partial birth abortion.² The legislation would modify the US Criminal Code to make it a federal crime for a physician or other individuals legally authorized by the state to perform an abortion that would "deliberately and intentionally deliver into the vagina a living fetus, or a substantial portion thereof, for the purpose of performing a procedure the physician knows will kill the fetus, and kills the fetus,"² unless the procedure was performed to save the life of the woman and there were no other alternative methods available. The physician would also be liable for monetary and statutory damages to the father of the fetus or the maternal grandparents of the fetus if the mother was younger than 18 years. The debate over this legislation generated heated controversy over the prevalence of late-term abortion, the specific procedures used to perform them, the reasons late-term abortions are performed, and the risk of death and complications for the woman related to late-term abortion.

This article presents scientific and medical information on late-term abortion and late-term abortion techniques. A discussion of the prevalence of induced abortion and limitations of data on abortion is followed by a description of reasons for late-term abortion. Procedures used to induce abortion at earlier and later stages of pregnancy are described, abortion-related mortality and morbidity are discussed, Supreme Court decisions on abortion are summarized, and policies of major medical societies on late-term abortion are presented.

Data on the prevalence of induced abortion were obtained from the Centers for Disease Control and Prevention (CDC), Atlanta, Ga, the Alan Guttmacher Institute (AGI), New York, NY, and the National Center for Health Statistics (NCHS), Washington, DC. Information on induced-abortion procedures and related complications is derived from English-language peer reviewed medical journals and medical textbooks, some of which were identified through computerized databases. Data on policies of major medical societies regarding late-term abortion were obtained from each of the medical societies.

In this article, early second-trimester abortion procedures refer to those performed at 13 through 15 weeks of gestation. Mid second-trimester abortion procedures are those performed at 16 through 19 weeks of gestation. Late second-trimester abortions refer to procedures performed at 20 through 27 weeks of gestation. Late-term abortions refer to procedures performed during the third trimester, defined as 27 weeks of gestation or more. Weeks of gestation are defined in terms of the first day of the last menstrual period. However, gestational age may vary depending on whether the stage of pregnancy is calculated from the first day of the last menstrual period, from the estimated time of fertilization, or from the estimated time of implementation.^{3 - 4} Such distinctions are important when regulations or legal provisions refer to weeks of gestation or trimesters.

Viability is presumed to exist after 27 weeks of gestation (assuming an otherwise healthy fetus) and is presumed not to exist prior to 20 weeks.^{5 - 7} The time between 20 and 27 weeks is a "gray zone" in which some fetuses may be viable and others are not. The definition of viability used herein is the same as that used by the US Supreme Court: "the capacity for meaningful life outside the womb, albeit with artificial aid," and not just momentary survival.⁸ The distinction between measuring viability in terms of weeks of gestation vs "meaningful life outside the womb, albeit with artificial aid" is important with respect to late-term abortion. It is not clear whether the proposed federal legislation would ban all third-trimester abortions or all postviability procedures, some of which may occur during the second trimester. Some medical procedures used to induce abortion prior to viability are identical or very similar to postviability abortion procedures.

The CDC defines an induced abortion as "a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."⁹ A molar pregnancy, ectopic pregnancy, or fetal death diagnosed before any intervention are not regarded as an induced abortion.

The most scientifically reliable national data on the incidence of abortion in the United States come from the CDC and the AGI. The AGI is an independent, nonprofit corporation for research, policy analysis, and public education. Because the number of late-term abortions performed annually has been questioned in the popular press, it is worth describing the type of national abortion statistics collected in the United States and methods of data collection. Both the CDC and AGI collect data on the number of abortions in the United States. The CDC data are derived primarily from reports by state health departments, whereas the AGI collects data directly from abortion providers. For many years, AGI estimates of the number of abortions performed in the United States each year have been higher and considered to be more accurate than CDC estimates.^{10 - 11} However, AGI collects national abortion data on a periodic basis, whereas the CDC has collected abortion-related data annually since 1970. Furthermore, the AGI does not collect data on gestational age. Instead, it uses CDC data on the number of abortions performed at various gestational ages and makes statistical adjustments for discrepancies between AGI and CDC data when publishing its estimates.

Because the CDC collects annual data on abortion primarily from state health departments, the data have limitations. First, some states—Alaska, California, Iowa, New Hampshire, and Oklahoma—neither collect nor report abortion-related information to the CDC. For these states, the CDC conducts limited surveys of abortion providers or estimates the number of abortions.¹⁰ Second, some state health departments lack information on 40% to 50% of abortions performed in the state.^{11 - 12} Third, categories used by the CDC to report second-trimester abortion methods differentiate between dilatation and evacuation (D&E) (also referred to as dilation and evacuation), labor induction procedures, and hysterotomy or hysterectomy, but they do not have a separate category for dilatation and extraction (D&X) (also referred to as dilation and extraction). Fourth, states vary in how gestational age is recorded. Some use the number of weeks since the first day of the woman's last menstrual period, while others record the physician's estimate of gestational age. Finally, although the CDC reports abortion data by gestational age, it neither compiles nor reports a detailed breakdown of abortions performed at 21 weeks and beyond. Despite these limitations, the CDC and AGI are the most reliable sources of national data on abortion.

The vast majority (95%) of induced abortions are performed at or before 15 weeks' gestation, in the first or very early second trimester (Table 1).¹² The estimated number of induced abortions at 21 weeks or more is shown in Table 2.¹² These estimates are based on CDC abortion surveillance reports, data collected by the NCHS from 14 states, and AGI survey data. Estimates were calculated by the AGI but must be viewed cautiously. First, the data were collected from 14 states that may not be representative of the nation as a whole, and reporting by these states may be incomplete. Second, assuming that the number of clinicians who perform late-term abortions is relatively small,¹² they may have relatively large caseloads. The number of late-term abortions would be underestimated if these clinicians were not in the NCHS sample or overestimated if they were overrepresented in the sample. Third, random error in coding gestational age could substantially inflate the estimated number of abortions performed beyond 26 weeks because these procedures constitute such a small proportion of abortions overall. Fourth, clinician errors in estimating gestational age could bias the data in unknown ways. Finally, natural fetal deaths beyond 20 weeks of gestation reported to the NCHS may be miscounted as abortions if the fetus were removed using procedures used to induce abortion.¹³

According to these estimates, two thirds of abortions beyond 20 weeks are performed between 21 and 22 weeks. The number of abortions performed after 26 weeks nationwide is estimated between 320 and 600. An estimated 83% of abortions performed later than 20 weeks of gestation are performed by D&E and most others by inducing labor.¹² It is not possible to quantify the type of D&E procedure used in these circumstances.

In 1994, teenagers were more likely than older women to have an abortion at 16 weeks of gestation or later.¹⁰ Seventeen percent of women 19 years of age or younger who had an abortion in 1994 had the procedure performed at 13 weeks of gestation or later, compared with 11% of women 20 years of age and older.¹⁰ Among women who had an abortion in 1994, 15% of women who were black or of other races had the procedure during the second or third trimester, compared with 10% of white women who did so. There were no differences between Hispanic and non-Hispanic women (12.8% and 12.6%, respectively).¹⁰

Little research has been done on reasons for induced abortion in the second trimester. In 1987, the AGI conducted a survey of patients in 30 abortion facilities in which at least 400 abortions were performed annually and in which they performed abortions at 16 or more weeks of gestation.¹⁴ The 30 abortion facilities represented each of the 4 regions of the country and the average patient response rate was 80%. Of the 1900 women in the survey, 420 (22.1%) had been pregnant for 16 weeks or more. When asked about the most important reasons for their delay in having an abortion, 71% reported that they did not recognize that they were pregnant or misjudged gestational age. Forty-eight percent had difficulty arranging for the abortion (particularly raising money), 33% were afraid to tell their parents or partner, and 24% reported great difficulty deciding to have an abortion. Women having an abortion later in pregnancy were also more likely to report personal health problems, possible fetal health problems, rape, or incest.

Some second-trimester abortions result from medical conditions that threaten a woman's health or life. The condition may have existed prior to the pregnancy, may have arisen during the pregnancy, or could have resulted from the pregnancy itself. Other second-trimester abortions result from the detection of serious fetal abnormalities, many of which are not diagnosed until the second trimester. Amniocentesis is usually performed between the 14th and 18th weeks of pregnancy, and results usually are not available for another 2 to 3 weeks.¹⁵ Chorionic villus sampling (CVS) can be performed between the 10th and 12th weeks of pregnancy.¹⁵ Preliminary results of CVS are usually available within 48 hours and confirmatory final results typically take a maximum of 7 to 10 days.¹⁵ An induced abortion prompted by the discovery of fetal anomalies through CVS or amniocentesis is almost certain to occur after the first trimester.

The procedure used to induce abortion depends, in part, on gestational age, commonly defined as the number of weeks since the first day of the last menstrual period, based on a 28-day menstrual cycle.⁴ The percentage of reported legal abortions by weeks of gestation and type of procedure is shown in Table 3.¹⁰ The most common procedures used to induce abortion in the United States (99%) are suction or sharp curettage and D&E. The D&E procedure is the most common method used in the second trimester, although about 6% of abortions at 16 to 20 weeks and 9% of those past 20 weeks are performed using labor induction techniques. Hysterotomy and hysterectomy are rare regardless of gestational age.

Since the 1970s, vacuum aspiration, also referred to as suction curettage, has been the most common procedure used to induce abortion in the first trimester (ie, through the 12th week of gestation).^{9 - 11} Menstrual regulation, also known as menstrual extraction, is a type of early suction curettage that can be performed no later than 42 to 50 days from the last menstrual period.¹⁶ Neither anesthesia nor dilation is usually necessary.

Pharmaceutical agents also have been used in first-trimester abortions. Mifepristone (RU-486), a synthetic hormone, can be used within 9 weeks of the last menstrual period. To induce abortion, the woman takes 1 oral dose of mifepristone followed a few days later by misoprostol to stimulate uterine contractions and expel the products of conception.¹⁵ Methotrexate used with misoprostol represents a second pharmaceutical approach.¹⁷ First-trimester procedures are typically performed on an outpatient basis.

The most common procedure to induce abortion during the second trimester is D&E, which refers generically to transcervical procedures performed at 13 weeks of gestation or later.^{10 ,18 - 20} Labor-induction techniques are also used during the second trimester but are more common in the late second and third trimesters.

The D&E procedure is similar to vacuum aspiration except that the cervix must be dilated more widely (usually with osmotic dilators) because surgical instruments are used to remove larger pieces of tissue. Ultrasonography frequently is used to avoid underestimating gestational age.^{16 ,21 - 24} Intravenous fluids and an analgesic or sedative may be administered; a local anesthetic such as a paracervical block may be used. Dilating agents are removed before instruments are inserted through the cervix and into the uterus to remove fetal and placental tissue. A curette is used to remove remaining tissue from the uterine walls. In pregnancies beyond 14 weeks, oxytocin may be given intravenously to stimulate the uterus to contract and shrink.^{15 - 16 ,25}

By the 16th to 24th week of gestation, several procedures can be used to induce abortion, although some are more common than others. These include D&E, D&X (a variant of D&E), labor induction, hysterotomy, and hysterectomy.

By the 16th week of gestation, ultrasonography should be used to verify gestational age.^{16 ,21 - 24} The D&E procedure is usually performed under local anesthesia, using sedation and paracervical block. Surgical instruments are used to extract the products of conception, followed by subsequent curettage.^{16 ,19 - 20} Because the fetus is larger (particularly the head) and because bones are more rigid at this stage of gestation, destructive procedures are more likely to be required than at earlier gestational ages. Some physicians use intrafetal or intra-amniotic administration of potassium chloride or digoxin to induce fetal demise prior to a late D&E (after 20 weeks) to facilitate evacuation.²⁵ Other physicians do not induce fetal demise through injection because of concern that it might expose some women to a small but unnecessary risk.

To minimize uterine or cervical perforation from instruments or from laceration by fetal parts, some physicians use a form of D&E that has been referred to as intact D&X. According to the American College of Obstetricians and Gynecologists (ACOG), intact D&X consists of the following elements: deliberate dilatation of the cervix, usually over a sequence of days; instrumental or manual conversion of the fetus to a footling breech; breech extraction of the body except the head; and partial evacuation of the intracranial contents of a living fetus to effect vaginal delivery of a dead but otherwise intact fetus.²⁶ However, there may be variations of D&X that depart from this protocol, such as when an identical procedure is performed without converting the fetus to a footling breech or using decompression without suction evacuation of the cranial contents. Intact D&X may minimize trauma to the woman's uterus, cervix, and other vital organs. Some physicians may use intact D&X when the fetus has been diagnosed as having anomalies incompatible with life outside the womb. However, some physicians have suggested that the procedure may increase complications, such as cervical incompetence.²⁷ In the absence of controlled studies, the relative advantages and disadvantages of the procedure in specific circumstances remain unknown.

As gestational age increases, particularly during the 16th to 24th weeks, the proportion of abortions involving labor-induction techniques increases.^{10 ,20} Labor-induction techniques can be subdivided by the type of abortifacient used (intra-amniotic hypertonic solutions, such as urea or saline) and prostaglandin inductions (eg, prostaglandin E₂ suppositories).^{16 ,23 ,28} The use of hypertonic solutions typically produces fetal death from osmotic insult and labor usually follows. In a saline abortion, a needle is inserted through the abdomen, the amniotic sac is injected with a concentrated salt solution, and this results in fetal demise and uterine contractions. Over several hours, the contractions cause the cervix to dilate and the contents of the uterus to be expelled. Alternatively, urea (a nitrogen-based solution that causes fetal demise when injected into the amniotic sac) may be used with subsequent administration of prostaglandins to induce contractions of the uterus and to expel its contents.¹⁵ Unlike saline instillation, urea does not cause maceration of fetal tissues which would interfere with the histologic diagnosis of some fetal abnormalities.²⁹

Hysterotomy and hysterectomy are used rarely to induce abortion because of the significantly greater maternal mortality and morbidity associated with these procedures compared with other abortion procedures.^{10 - 11 ,20 ,30 - 31} Hysterotomy involves the surgical delivery of the fetus through an incision in the uterine wall and abdomen. Anesthesia is administered through epidural, spinal, or general anesthesia. Hysterotomy involves major surgery, must be done in a hospital, and lengthens a woman's hospital stay and recovery.¹⁵ Hysterectomy may be appropriate in cases involving a preexisting pathologic condition, such as large uterine leiomyomas or carcinoma in situ of the cervix.¹⁶

Abortion-related mortality refers to the death of the pregnant woman due to an abortion.¹⁹ Abortion mortality may result from a legal, illegal, or spontaneous abortion or an abortion of unknown circumstances. The risk of abortion-related mortality increases with gestational age. In 1991, the overall case-fatality rate associated with legal abortions was 0.8 per 100000 abortions.¹⁰ The risk of mortality from induced abortion at 8 weeks' gestation or less was 0.2 per 100000 procedures and by 16 to 20 weeks increased to 5.9 per 100000 procedures.³² At 21 weeks or more, the mortality rate was 16.7 per 100000 procedures³² and exceeded the risk of maternal death from childbirth, which was 6.7 per 100000 deliveries,^{33 - 34} although the difference was not statistically significant.

Abortion-related mortality rates associated with D&E, labor induction, and hysterectomy or hysterotomy at 13 weeks' gestation or later are shown in Table 4.³⁵ For all types of procedures, mortality rates increase with gestational age, but they are significantly greater for hysterectomy and hysterotomy, regardless of gestational age. Mortality rates, overall, are higher for abortion-related labor induction than D&E (7.1 and 3.7, respectively) but are comparable for induced abortions performed at 21 weeks or more (11.9 and 10.3, respectively).

It is difficult to estimate abortion-related morbidity because definitions of what constitutes a complication vary widely and because in the United States national data on abortion-related morbidity have not been collected on a systematic, ongoing basis. The best available national data on complications were collected during the 1970s by the Joint Program for the Study of Abortion (JPSA), sponsored by the Population Council, New York, NY, and the CDC.³⁶ The JPSA consisted of 3 prospective studies of abortion between 1971 and 1978, involved a sample of hospitals and clinics throughout the United States, and included 73000 to 84000 women in each phase of the research program.

The most common indicator of abortion-related morbidity is hospital admission. This excludes minor physical sequelae but includes more serious maternal consequences of induced abortion. The JPSA studies defined major complications from induced abortion as those that result in major unintended surgery, hemorrhage requiring a blood transfusion, hospitalization of 11 days or more, or temperature of at least 38.0°C (100.4°F) that lasts for 3 or more days.³⁷

Between 1970 and 1990, the overall risk of major complications from abortion-related procedures declined dramatically. From 1970 to 1971 there were 8 major complications per 1000 patients who had abortions but who did not have a preexisting medical condition or did not undergo concurrent sterilization.³⁸ Between 1975 and 1978, the rate decreased to 5 major complications per 1000 abortions,³⁸ and by 1990, the National Abortion Federation, Washington, DC, estimated that there was 1 major complication per 1000 abortions.³⁹ The overall decline in complication rates probably can be attributed to an increased proportion of procedures being performed earlier in the pregnancy and improvements in medical technology, medical training, and the experience and skill of those performing the procedure.

The risk of complications is related to abortion method. Between 1975 and 1978, the last years of the JPSA, the complication rate associated with vacuum aspiration was 2 per 1000 procedures, and the complication rate for D&E was 7 per 1000 procedures. Procedures that induced labor (saline or prostaglandin instillation) had a higher rate (21 and 25 per 1000 procedures, respectively), and those involving major surgery had the highest rate of complications.³⁸

The risk of complications and complication rates from induced abortion are also related to gestational age. From 1975 to 1978, there were between 1 and 4 major complications per 1000 procedures performed through the 12th week of gestation,¹⁶ 6 major complications per 1000 procedures performed in weeks 13 to 14, 13 per 1000 in weeks 15 to 16, and 19 per 1000 in weeks 17 to 20.¹⁶

More recent international data also have shown that complication rates still increase with gestational age. Direct comparisons of abortion-related complication rates between countries must be made cautiously due to differences in the definition and measurement of complications. Data from 1988 for Denmark, Germany, and New York State and from 1987 for Canada, England, and Wales showed complication rates ranging from 0.4% to 3.4% for first-trimester abortions and from 1.1% to 8.7% for second-trimester abortions.⁴⁰

Cervical incompetence and compromised subsequent pregnancies are important but unresolved concerns related to second- or third-trimester abortions. Little research exists on whether these complications are more likely to result from D&E (or intact D&X) or from labor-induction techniques. For second-trimester abortions, some physicians prefer D&E over labor-induction methods because D&E has a lower mortality rate, takes less time, is less expensive, can be done on an outpatient basis, and takes less of a psychological toll on some women because it does not imitate labor.^{17 ,20 ,41 - 42} Other physicians prefer to induce labor because they find the labor induction method less distasteful.⁴¹ Still others prefer the labor induction method because they feel that it interferes less with the diagnosis of cytogenetic, anatomical, or DNA abnormalities in the fetus, particularly if saline instillation is avoided.⁴³ However, a study involving 60 patients who underwent D&E at 14 to 22 weeks of gestation after fetal abnormalities were detected found that D&E successfully and consistently confirmed abnormal prenatal diagnoses.²⁹

Abortion-related morbidity is lower for D&E procedures than for labor-induction methods used in second-trimester abortions. However, the rates are similar for procedures performed at 20 weeks' gestation and beyond. More research on complications and complication rates associated with various procedures and by gestational age is needed before firm conclusions about the relative safety of procedures can be drawn.

Induced abortion through the first trimester was legal under common law in the United States until the middle of the 19th century.⁴⁴ By 1965, abortion and abortion attempts at all stages of pregnancy were prohibited by law, although in 46 states and the District of Columbia abortion was permitted to save the life of the pregnant woman. Similar exceptions to the statutory prohibition were made through judicial interpretation in 2 other states.⁴⁵ During the late 1960s, state legislatures began to reconsider the legalization of abortion, and, in January 1973, abortion became legal on a national basis as a result of US Supreme Court decisions in Roe v Wade and Doe v Bolton, (410 US 179 [1973]).

In Roe v Wade and Doe v Bolton, the US Supreme Court held that states could not interfere with the physician-patient decision about abortion during the first trimester of pregnancy. After the first trimester and prior to fetal viability, the state could promote its interest in the health of the mother by regulating the abortion procedure in ways reasonably related to maternal health. Maternal health included physical, emotional, and psychological well-being, familial factors, and the woman's age.⁴⁶

In Roe v Wade, the Supreme Court noted that the timing of viability can be difficult to establish precisely. The Court defined viability as "the capacity for meaningful life outside the mother's womb, albeit with artificial aid," and not just momentary survival. The Court noted that viability usually occurred at approximately 28 weeks but could occur as early as 24 weeks.⁸ The Court stated that it is the professional responsibility of the physician to determine whether the fetus has the capacity for meaningful life and not merely temporary survival. For the stage subsequent to viability, the Court determined that the state could regulate and even proscribe abortion unless it was deemed by medical judgment to be necessary to preserve the life or health of the pregnant woman.⁸

In Planned Parenthood of Central Missouri v Danforth (428 US 52 [1976]), the Court stated that "[t]he time when viability is achieved may vary with each pregnancy, and the determination of whether a particular fetus is viable is, and must be, a matter for the judgment of the responsible attending physician."⁴⁷ The Court rejected the argument that state legislation should specify a number of weeks as the point of viability, reaffirming that the onset of viability was essentially a medical concept, not an issue for legislative determination.⁴⁷

However, in Webster v Reproductive Health Services (492 US 490 [1989]), the Supreme Court upheld a state statute that created "what is essentially a presumption of viability at 20 weeks, which the physician must rebut with tests indicating that the fetus is not viable prior to performing an abortion."⁴⁸ In Planned Parenthood of Southeastern Pennsylvania v Casey, (505 U.S. 833 [1992]), the Court acknowledged that advances in neonatal care moved viability to a point somewhat earlier than when Roe v Wade was decided but noted that this had "no bearing on the validity of Roe's central holding, that viability marks the earliest point at which the State's interest in fetal life is constitutionally adequate to justify a legislative ban on nontherapeutic abortions."⁴⁹

In Colautti v Franklin (439 US 379 [1979]), the Supreme Court struck down a statute subjecting physicians who performed an abortion to potential criminal liability if they failed to attempt to preserve the life of a viable or potentially viable fetus. The Court expressed uncertainty as to whether the statute permitted physicians to consider their duty to the patient to be paramount to their duty to the fetus or whether it required physicians to make a "trade-off" between the woman's health and additional percentage points of fetal survival. The Court held that where conflicting duties of this magnitude are involved, the state must proceed with greater precision before subjecting a physician to possible criminal sanctions.

The Court also addressed the balance of maternal and fetal interests in Thornburgh v American College of Obstetricians and Gynecologists (476 US 747 [1986]). The Supreme Court struck down a provision requiring every person who performs a postviability abortion to exercise the degree of care required to preserve the life and health of any unborn child intended to be born and not aborted. It also invalidated a provision requiring that the abortion technique used would maximize the likelihood that the unborn child would be aborted alive unless, in the judgment of the physician, that technique significantly increased medical risks to the life or health of the pregnant woman. The statute was found to be unconstitutional because it could be construed to require the mother to bear an increased medical risk in order to save her viable fetus.

Some medical societies have developed specific policies regarding late-term abortion. ACOG was the first medical specialty society to oppose the Partial Birth Abortion Act of 1995 and develop policy on intact D&X. In November 1995, ACOG released a statement expressing its disappointment that Congress "has attempted to regulate medical decision-making . . . by passing a bill on so-called ‘partial-birth' abortion . . . [T]he College finds . . . very disturbing . . . any action by Congress that would supersede the medical judgment of trained physicians and that would criminalize medical procedures that may be necessary to save the life of a woman."⁵⁰ In January 1997, ACOG released a Statement of Policy on Intact D&X, which explained that intact D&X contains 4 specific elements (see "Procedures to Induce Abortion, Mid Second Trimester and Third Trimester" section).²⁶ The policy noted that "because these elements are part of established obstetric techniques, . . . unless all four elements are present in sequence, the procedure is not an intact D&X."²⁶ Furthermore,

when abortion is performed after 16 weeks, intact D&X is one method of terminating a pregnancy. The physician, in consultation with the patient, must choose the most appropriate method based on the patient's individual circumstances. . . Terminating a pregnancy is performed in some circumstances to save the life or preserve the health of the mother. Intact D&X is one of the methods available in some of these situations. A select panel convened by ACOG could identify no circumstances under which this procedure, as defined above, would be the only option to save the life or preserve the health of the woman. An intact D&X, however, may be the best or most appropriate procedure in a particular circumstance to save the life or preserve the health of a woman, and only the doctor, in consultation with the patient, based upon the woman's particular circumstances can make this decision. The potential exists that legislation prohibiting specific medical practices, such as intact D&X, may outlaw techniques that are critical to the lives and health of American women. The intervention of legislative bodies into medical decision-making is inappropriate, ill-advised, and dangerous.²⁶

In June 1997, the AMA House of Delegates adopted recommendations on late-term abortion and abortion techniques.¹ The recommendations reaffirmed AMA policies regarding abortion (5.990, 5.993, and 5.995) that state that the early termination of pregnancy is a medical matter between the patient and physician subject to the physician's clinical judgment, the patient's informed consent, and the availability of appropriate facilities. The AMA policy also states that abortion is a medical procedure and should be performed by a physician in conformance with standards of good medical practice and that support of or opposition to abortion is a matter for members of the AMA to decide individually, based on personal values or beliefs. The AMA will take no action that may be construed as an attempt to alter or influence the personal views of individual physicians regarding abortion procedures. Also reaffirmed was the policy that neither physician, hospital, nor hospital personnel shall be required to perform any act violative of personally held moral principles (Amended Resolution 158, A-90); (Resolution 49, I-89) (Substitute Resolution 43, A-73; Reaffirmed: I-86; Reaffirmed: Sunset Report, I-96; Reaffirmed by Substitute Resolution 208, I-96).

Additional recommendations were also adopted. First, the AMA noted that because partial birth abortion is not a medical term the AMA would not use it. Instead, the term intact dilatation and extraction (or intact D&X) should be used when referring to a specific procedure comprising the following elements: deliberate dilatation of the cervix, usually over a sequence of days; instrumental or manual conversion of the fetus to a footling breech; breech extraction of the body except the head; and partial evacuation of the intracranial contents of the living fetus to effect vaginal delivery of a dead but otherwise intact fetus. This procedure is distinct from D&E procedures, which are more commonly used to induce abortion after the first trimester.

Second, the AMA recommended that the intact D&X procedure not be used unless alternative procedures pose materially greater risk to the woman. It is the physician, however, who must retain the discretion to make that judgment, acting within standards of good medical practice and in the best interest of the patient.

Third, because the viability of the fetus and the time when viability is achieved may vary with each pregnancy, it is the physician who should determine the viability of a specific fetus, using the latest available diagnostic technology. In addition, the AMA recommended that abortions not be performed in the third trimester except in cases of serious fetal anomalies incompatible with life. According to the recommendation, except in extraordinary circumstances, maternal health factors that demand termination of the pregnancy can be accommodated without sacrifice of the fetus, and the near certainty of the independent viability of the fetus argues for ending the pregnancy by appropriate delivery.

The AMA also resolved to work with ACOG to develop clinical guidelines for induced abortion after the 22nd week of gestation and the American Academy of Pediatrics to develop clinical guidelines with respect to fetal viability during gestation and its impact on this procedure.

The AMA urged the CDC as well as state health department officials to develop expanded, ongoing data surveillance systems of induced abortion. Finally, the AMA resolved to work with appropriate medical specialty societies, government agencies, private foundations, and other interested groups to educate the public regarding pregnancy prevention strategies, with special attention to at-risk populations, which would minimize or preclude the need for abortions.

As of December 1997, the American Academy of Family Physicians and the American Academy of Pediatrics had not issued policies on late-term abortion.