The Continuing Need for Late Abortions

LATE ABORTION is the most controversial aspect of the most divisive social issue of our times.¹ The debate has been strident, confusing, and at times, misleading.² This article reviews the epidemiology of late abortion, defined herein as abortions performed 21 or more completed weeks from the beginning of last menses (this gestational age interval is the highest used in federal reports on abortion^{3 - 4} ); discusses the frequency, methods, safety, and indications of late abortions; and describes controversies concerning the upper gestational age limit and attempts to prohibit a specific abortion method.

For decades, late induced abortions have been uncommon in the United States. From 1972 through 1992, the proportion of all induced abortions that were performed at 21 or more weeks' gestation ranged from 0.8% to 1.7%.³ The upper gestational age limit varies by state. However, the claim that many women have elective abortions in the third trimester lacks support. Most reports of abortions at 25 or more weeks' gestation are due to reporting errors or to fetal demise. Between 1979 and 1980, only 3 cases of approximately 70000 reported induced abortions in Georgia took place at 25 weeks or more. Two procedures were performed for fetal anencephaly, and insufficient information was available for the third.⁵ This is believed to be the only published article on this procedure.

Dilation and evacuation (D&E) is the most frequent method used for late abortion in the United States. In 1992, D&E accounted for 86% of all abortions at 21 or more weeks' gestation, whereas labor induction accounted for 14%.³ Hysterotomy or hysterectomy were rare (0.1%). Hysterotomy should play no role in contemporary abortion practice. Hysterectomy is appropriate only when existing pathological findings, such as carcinoma in situ of the cervix, would warrant the operation.

Dilation and evacuation involves outpatient preoperative dilation of the cervix by osmotic dilators, such as laminaria, over 1 or more days. The evacuation then occurs on an outpatient basis under local or general anesthesia. The operation is begun by draining the amniotic fluid with a suction cannula. The physician then evacuates the uterus with special grasping forceps. Ultrasound to confirm gestational age is routine before D&E. Use of ultrasound guidance during the procedure appears to reduce the risk of uterine perforation when resident physicians are learning the procedure.

Intact dilation and extraction (intact D&E), a variant of D&E, involves wide cervical dilation by osmotic dilators, internal podalic version, then total breech extraction. The skull is collapsed (cephalocentesis) to allow a smaller diameter to pass through the cervix, thus reducing risk of cervical injury. Although no data exist on the frequency of this operation,³ only a small number of physicians nationwide perform this procedure. It may be especially useful in the presence of fetal anomalies, such as hydrocephalus.

Unlike D&E, labor-induction abortion usually requires hospitalization. Physicians induce labor with uterotonic agents, hypertonic solutions, osmotic cervical dilators, or a combination of these. Uterotonic agents include prostaglandins, given as vaginal suppositories (prostaglandin E₂), intramuscular injections (15-methyl-prostaglandin F_2α), or medication taken orally or vaginally (misoprostol). High-dose intravenous oxytocin appears to offer similar efficacy as vaginal prostaglandin E₂ with fewer gastrointestinal side effects. Alternatively, some physicians use hypertonic solutions, such as 200 mL of 20% saline solution, injected into the amniotic cavity to induce labor. As augmenting agents, osmotic dilators shorten the induction-to-abortion times and reduce the risk of cervical injury. Narcotics or, less commonly, epidural anesthesia are given for pain.⁶

Although the risk of abortion morbidity and mortality increases as pregnancy advances, late abortion (≥21 weeks' gestation) remains a safe procedure. Nationwide surveillance of abortion mortality provides the best contemporary assessment.⁴ From 1972 through 1987, the risk of death associated with D&E at 21 or more weeks' gestation (11.9 deaths per 100000 procedures) was similar to that with labor induction (10.3 deaths per 100000 procedures) (Table). Both compare favorably with overall pregnancy-related mortality rates in the United States (9.1 to 23.5 deaths per 100000 live births).⁷

No contemporary studies have directly compared the morbidity risks of late D&E and labor induction. One natural experiment, however, provided useful insights. An experienced team of 4 gynecologists gradually switched from labor induction abortions to D&E.⁸ Their inexperience with the latter technique should have biased this comparison against D&E. Nevertheless, the transition to D&E led to a 90% reduction in serious complications. Among 3711 second-trimester abortions, the serious complication rate per 100 operations was only 0.23 with D&E.⁸ The corresponding figures for labor induction with prostaglandin F_2α or with hypertonic saline were 1.28 and 2.26, respectively. A recent case-series study of D&E abortions suggested that the morbidity rate was even lower than with first-trimester suction curettage (2.9 vs 5.1 per 100 operations).⁹

Other considerations have contributed to the dominance of D&E abortion in US practice. Compared with labor induction, D&E is preferable in terms of compassion, cost, comfort, and convenience. Negative reactions to second-trimester abortion are directly related to contact with the fetus. Aborting a fetus can be emotionally difficult for women, especially for those who are alone in a hospital in the middle of the night. In contrast, during D&E abortion women have no contact with the fetus. The operation transfers the emotional burden of abortion from women, who have often suffered greatly, to the staff. Dilation and evacuation abortion obviates the need for costly overnight stays in hospital, as is customary with labor induction. Women having D&E abortions are spared a "maxi-labor" followed by a "mini-delivery." Instead of enduring labor, women receive local or general anesthesia for the brief operation. Finally, because D&E abortion takes place on an outpatient basis, women's lives are less disrupted than with hospitalization for 1 or more nights.

Women who have late abortions often are disadvantaged. Teenagers, especially those younger than 15 years, and women of minority status disproportionately have late abortions.³ Many of these patients either do not suspect the pregnancy or attempt to conceal it until the pregnancy becomes evident. Menstrual irregularity is an important risk factor.¹⁰ Women with irregular menses often discover late that they are pregnant. Other risk factors include young age, low educational attainment, having had a sexually transmitted disease, and ambivalence about the decision to abort.¹¹ Thus, many of the factors associated with late abortions are not easily changed.

Women seeking late abortions are often disadvantaged in other ways, such as lack of knowledge about options, lack of money to pay for the procedure, lack of transportation to a provider, and alcohol or other drug dependence. Some young women are unaware of the availability of late abortions. Since enactment of the Hyde Amendment, the federal government has not paid for indigent women to have abortions, and few states subsidize abortion services. Hence, some women need weeks to raise the money to pay for an abortion, which delays the procedure until the second trimester. Of note, states that fund abortions have significantly lower rates of teen pregnancy, low-birth-weight babies, premature births, and births with late or no prenatal care than do other states.

Geography poses yet another barrier: more than 80% of US counties do not have an abortion provider. Providers of late abortion are even more scarce. In 1993, only 13% of US abortion providers offered abortions at 21 weeks, and the cost averaged more than $1000.¹²

Late abortions are fundamentally important to women's reproductive health.¹ Antenatal fetal diagnosis, such as maternal α-fetoprotein screening and amniocentesis, is predicated on the availability of induced abortion. Although techniques such as chorionic villus sampling and early amniocentesis have allowed earlier diagnosis, by the time results of midtrimester amniocentesis or ultrasound are available, a woman may be beyond 20 weeks' gestation.¹³

Ironically, the availability of late abortion is pronatalist. About 98% of women who undergo genetic screening receive reassuring news.¹⁴ Without the availability of prenatal diagnosis with abortion as an option, many of these women would not have become pregnant or would have aborted all pregnancies that occurred.¹⁵ As noted by Cook,¹⁶ "Macroethical reasons favouring legal abortion in such circumstances rest on the potential to do greater good than harm in the community, and reveal the positive, life-affirming aspects of legally available abortion services."

Illnesses of women and fetal anomalies lead to requests for late abortions. Late abortion can be lifesaving for women with medical disorders aggravated by pregnancy.¹⁷ Conditions such as Eisenmenger syndrome carry a high risk of maternal morbidity and mortality in pregnancy, the latter ranging from 20% to 30%.¹⁸ In recent years, I have performed late abortions for a Kampuchean refugee with craniopagus conjoined twins and a 25-year-old woman with a 9 × 15-cm thoracic aortic aneurysm from newly diagnosed Marfan syndrome. Cancer sometimes makes late abortion necessary. For example, either radical hysterectomy or radiation therapy for cervical cancer before fetal viability involves abortion.

Incest and rape are other compelling indications. Pregnancies resulting from incest among young teenagers or among women with mental handicaps may escape detection until the pregnancy is advanced. Approximately 32000 pregnancies result from rape each year in the United States; about half of rape victims receive no medical attention, and about one third do not discover the pregnancy until the second trimester.¹⁹

The appropriate upper gestational age limit for abortion remains elusive. Most Americans reject absolutist positions on abortion. Absolutist positions are problematic "because no such account can claim final intellectual or moral authority, given the necessarily disputable nature of all accounts of the independent moral status of the fetus."²⁰

Instead, most Americans choose the moderate or gradualist view. This holds that the fetus gains increasing human worth as pregnancy advances. "The main difficulty with moderate views of abortion is that they lack the precision of the liberal and the conservative views. Knowledge of fetal development is constantly increasing and no sharp divisions can be drawn between one stage and the next."²¹ Given these ambiguities, compassion, tolerance, and judgment are needed to balance the competing interests of fetus, woman, and society.

Some argue that the gestational age limit for abortion should be the point of viability. This is a shifting target, and physicians cannot predict the probability of extrauterine survival for a given fetus. However, few abortion supporters would consider elective abortion after viability morally acceptable, except in rare circumstances in which the fetus has an anomaly incompatible with life.²² Others²³ claim that neurological development should define the limit: when the fetus becomes sentient, abortion should be impermissible.

Women ultimately determine the status of the fetus. "Thus, before viability, a pregnant woman is free to withhold, confer, or, having once conferred, withdraw the status of being a patient from the fetus." In other words, "for secular gynecologic ethics, the abortion controversy regarding previable fetuses is resolved for physicians by the autonomous decision of the woman regarding her pregnancy and the dependent moral status of the fetus as a patient."²⁰

In Roe v Wade (410 US 113, 93 [SCt 1973]) the US Supreme Court gave states the right to regulate or prohibit abortion after the time of fetal viability, except when abortion is necessary to preserve the life or health of the pregnant woman. Since 1973, the US Supreme Court has repeatedly ruled that determinations about viability, choice of abortion method, and medical necessity should be left to physicians and not to legislatures. For example, in Planned Parenthood of Central Missouri v Danforth (428 US 52, 96 [SCt 1976]) the Supreme Court ruled that "it is not the proper function of the legislature or the courts to place viability, which is essentially a medical concept, at a specific point in the gestation period." The Supreme Court views governmental intrusion in the practice of medicine as both improper and ultimately harmful to the patient.

Nevertheless, some federal and state legislators have attempted to ban intact D&E. These efforts are misguided. When a licensed physician is practicing within relevant state and institutional regulations, the choice of an abortion method should be unencumbered by politics. The same holds true for other medical treatments.

The current legislative attack against intact D&E is the antithesis of public health practice. For example, 15 years ago a cluster of abortion-related deaths occurred at an abortion clinic in Miami, Fla. Cooperation among local, state, and federal health and law enforcement agencies led to criminal charges against those responsible. A clear public health problem led to corrective action.

In contrast, without any evidence^{3 - 4} to suggest that intact D&E is dangerous or ineffective, opponents of abortion have mounted a vigorous "corrective action." The only epidemic afoot is "a recurring outbreak of abortion politics" and "an epidemic of abortion bills."²⁴ Attempting to legislate abortion out of existence is, however, not a novel tactic.

As noted by the American College of Obstetricians and Gynecologists,²⁵ "The intervention of legislative bodies into medical decision making is inappropriate, ill advised, and dangerous." Moreover, these bans serve no legitimate health purpose as set forth by the US Supreme Court in Planned Parenthood of Southeastern Pennsylvania v Casey (505 US 833, 112 [SCt 1992]). Current attacks on late abortion stem from politics and ideology, not from public health, medicine, or concern for women. Indeed, preoccupation with the fetus can lead to ignoring the woman altogether. Like much of surgery, late abortion by any method is not aesthetic. However, these considerations must never influence the judgment of the physician as to what is best for the patient.

If late abortions were restricted or eliminated, the alternatives that would remain for women would include illegal abortion, adoption, and rearing a child initially unwanted. Studies of women denied abortions have provided important insights.²⁶ Some women denied abortion seek the procedure elsewhere and succeed; the high rates of reported spontaneous abortion among women in these studies are suspicious. Few women (7%-19%) place their children for adoption.

Children born after their mothers are denied abortion face serious challenges. In a classic study from Scandinavia, these children had a more insecure childhood, more delinquency, more psychiatric care, and more early marriages than did children in a comparison group.²⁶ Another study found worse school performance, more neurotic symptoms, and more registrations with social welfare authorities.²⁶ A study from Prague, Czech Republic, found significantly more serious behavior disorders and continued deterioration in school performance. By the time these children had reached their early 20s, they had significantly more job dissatisfaction, fewer friends, and greater dissatisfaction with life in general. Although the findings were not statistically significant, such children also had less education, more criminality, and more registrations for alcohol and other drug problems.²⁶ Denying requested abortions has adverse consequences that persist at least into early adulthood.

As noted by Macklin,²⁷ "The three leading principles of bioethics—respect for persons, beneficence and justice—together provide an ethical mandate for guaranteeing to women throughout the world a legal right to safe abortion." This mandate is especially important for the immature, disadvantaged, and often seriously ill women requesting late abortions in the United States. Regardless of political views on abortion, the scientific evidence is clear and incontrovertible: legal abortion, including late abortion, has been a resounding public health success.

Early abortion is safer, simpler, and less controversial than late abortion. Improving sex education, promoting access to safe and effective contraception, and removing economic and geographic barriers to early abortion can help to reduce the number of late abortions. This is a goal around which there should be broad consensus. Nevertheless, as experience has revealed,³ the need for late abortion will not disappear. Hence, our continuing responsibility as physicians and as a society is to ensure that these procedures are as safe, comfortable, and compassionate as possible. Women deserve no less from their physicians.