Posted November 16, 2001
This resource is now available as an edited, bound booklet.
(include full name, mailing address, and number of copies).
The 1997 General Assembly issued a statement in which it expressed a "word of counsel to the church and our culture that the procedure known as Intact dilatation and extraction (commonly called "partial birth" abortion) of a baby who could live outside the womb is of grave moral concern and should be considered only if the mother's physical life is endangered by the pregnancy." Since that time the Episcopal and Methodist denominations have also gone on record in opposition to abortions of viable unborn babies.
The Advisory Committee on Litigation (ACL) and the Advisory Committee on Social Witness Policy (ACSWP), General Assembly committees concerned with public policy issues, asked the G.A. in 2000 to seek a clarification of our denomination's policy on late term abortion. The ACL recently sent the draft of a report on the subject to ACSWP. The two committees are negotiating changes in language that could have a significant negative effect on the statement of 1997. Erik Nelson, research assistant for the Institute on Religion and Democracy, attended the recent (Oct. 18-21) ACSWP meeting in New York. His report is on this web site.
Pediatrician and PPL board member Patricia Lee June, M.D., sent a comprehensive report to the ACL on the subject of viability and late term abortion. Her report is posted here with her permission.
Appendix A, Glossary
Appendix B, Case histories where termination of pregnancy was necessary to safeguard the mother
September 14, 2001
Advisory Committee on Litigation
100 Witherspoon St
Louisville, KY 40202
Attn: Judy Woods
Cc: Advisory Committee on Social Witness Policy
Thank you very much for the opportunity to present written testimony to supplement the verbal testimony I gave at the Open Hearings on Post-Viability Abortions during General Assembly in June 2001.
I am a member (deacon) of First Presbyterian Church in Moultrie, GA, Flint River Presbytery and a physician Board Certified in both Internal Medicine and Pediatrics. Following my return from a 3 ½ year term as a missionary appointed by the UPC-USA/PCUS (PC (USA)) in Bangladesh, I have been in the solo practice of pediatrics in Moultrie, GA since 1984.
I will primarily address medical aspects of post-viability abortions, though I will include and close with some theological observations.
What is viability? (Please see Appendix A, Glossary, now for definitions and comments on this and other terms. This paper will be clearer if you read through the Glossary first.)
We can never predict viability with 100% accuracy for any child (prenatally or postnatally); indeed, none of us knows how many days we may have. Even a child born after an apparently uncomplicated term pregnancy may have an unrecognized lethal defect and conversely, children have been misdiagnosed even with anencephaly. Despite these limitations, we can make statistical predictions of viability depending upon gestational age, predicted weight, gender, race, and prenatal diagnosis of abnormalities. Viability in the second trimester at equal gestational age is higher for heavier babies, African-American compared to Caucasians, and females, though these differences become less important in the third trimester and race is reversed by term and weight over ten pounds is a liability.
While there are anecdotal reports of survival at 20 weeks gestation (not well documented), a 4% survival rate in Japan at 21 weeks (2.5% in one study in US), viability at 22 weeks varies considerably by hospital and by whether babies born at this age are given the necessary medical support. Survival rates at the best centers are 12-14% at 22 weeks; 15-42% at 23 weeks; and 47-83% at 24 weeks gestation. Generally speaking, these figures represent survival to going home. While mortality for premies continues to be higher than for term babies throughout the first year after birth, the vast majority of babies that survive to go home will survive for many years. Likewise, most babies who die will die soon after birth, with the earliest and smallest dying the most rapidly. Actually, babies born at younger that 20 weeks sometimes survive briefly after birth: I have personally cared for 3 children born at 16 and 18 weeks gestation who lived for 30 minutes and 2 hours respectively after birth. (When there is no chance for long-term survival, comfort care rather than maximum medical support is given.)
HOW MANY ABORTIONS ARE DONE AFTER VIABILITY?
The latest report from the Centers for Disease Control (CDC) is for 1997 when 1.4% of 1,189,039 abortions (16,600 abortions) done at or after 21 weeks gestation were reported to State Health Departments. The Alan Guttmacher Institute, an organization associated with Planned Parenthood, the nation’s largest abortion provider, also collects statistics on abortion directly from abortion providers and reported 12% more abortions in 1997 than were reported to the CDC. While they report 1% of abortions at 21 or more weeks, their percentages are all rounded off to the nearest even number (so the CDC’s 1.4% would become 1%), and their Facts in Brief sheet does not list actual number at gestational age, but only percent. Adjusting for a 12% undercount by the CDC would give an estimated 18,600 post-viability abortions in 1997. Alan Guttmacher figures for 1997 come to 13,300 to 18,620 (at 1% and 1.4% respectively).
Why are abortions done after viability? Theoretical reasons fall into three categories: life or health of the mother, fetal abnormality, or socio-economic reasons. According to Dr. Martin Haskell, who has performed over 700 "D&X" abortions, 80% of these are "purely elective" and 20% are for genetic reasons. According to testimony given before Congress by the late Dr. James McMahon who did over 2000 "intact D&E" procedures, 9% were for maternal health reasons (most commonly depression) and 56% were for "fetal flaws" (some as minor as a cleft lip). Dr. Leroy Carhart, speaking before the Assembly Committee on Health and Social Issues in 2001, responded to a question pertaining to why these abortions are done by asking if it wasn’t better for these young girls to have them than to have to decide early without thinking it over? I can affirm that he said nothing about maternal health or life or even about fetal abnormalities and that the question lent itself to an answer along those lines.
Let us look at these reasons, starting with the most serious, maternal life.
LIFE OF THE MOTHER
There are times when it is necessary to terminate a pregnancy to save the life of the mother: ectopic pregnancies, invasive carcinoma of the cervix, severe pregnancy-induced hypertension and eclampsia, severe congestive heart failure, unresponsive status asthmaticus, and placental abruption to name the most common reasons. When termination of pregnancy is required prior to fetal viability, there is a choice between doing nothing and having both mother and baby die, or sacrificing the baby while trying to save the mother. I know of very few people who would opt for 2 deaths instead of one. However there are certainly varying degrees of clinical skill in caring for gravida and fetus when their lives hang in the balance, and except for ectopic pregnancy, which is 99.9999% fatal to the embryo, induced abortion should not be performed except in an emergency (e.g., massive hemorrhage) without the concurrence of an obstetrician specializing in high-risk obstetrics. I personally have seen a general obstetrician perform abortions on an embryo and on a previable fetus "to save the life of the mother" where another physician later reviewed the chart and felt that the pregnancy could have been continued safely.
When termination of pregnancy is necessary to preserve the life or health of the mother after the unborn child may be viable, the question is, how should this termination be done? I stated in my oral testimony that it is never necessary to kill a viable fetus to save the life of the mother, but that pregnancy can be terminated by either inducing labor or by doing a Caesarian section (C/S). Not every baby will survive (actually even when there are no apparent problems after a full-term pregnancy, not every baby survives), but the physician has given both mother and child the best opportunity for life.
You told me you had not heard this before, and asked me for supporting data. I do need to make one clarification: With modern medicine, it is never necessary to kill a viable fetus to maintain the life of the mother. There may be cases of severe cephalo-pelvic disproportion (head too large for the pelvis) when decompression of the baby’s head may allow expulsion of the stillborn baby and save the mother when facilities for C/S are not available (in the remote bush in Africa, in the mountains of Nepal, etc). The rest of this paper will assume the standard level of care available in all but the most remote areas of the world.
The most outstanding feature of my search for data on this subject was its very lack. (Two medline searches are available upon request.) While almost every article (and an entire book) I found on second trimester abortion discussed social issues or the issue of fetal abnormality, only five addressed the issue of maternal health or life as an etiology. One discusses D&E abortion in critically ill women at 20-24 weeks, and recommended D&E over intraamniotic installation methods of abortion, but did not consider the option of delivery. This article was from the pre-surfactant era (cases were from Jan 1983-Jan 1987) when viability was not even being reported under 23 weeks, and the 2 of 13 cases at 23 and 24 weeks were among the first 4 listed, and presumably also occurred before the first reports on viability at these ages. Williams Obstetrics mentions persistent heart disease after previous cardiac decompensation, advanced hypertensive vascular disease, and invasive carcinoma of the cervix as medical indications for abortion in the chapter on abortion, but mentions no timing and presumably is referring to early abortion though this cannot be said for sure.
Interestingly, abortion is not again mentioned in the later discussion on how to care for a woman with severe hypertensive disease or congestive heart failure. Abortion for severe pulmonary hypertension/Eisenmenger syndrome is recommended, but post-viability abortion is not specifically mentioned, and newer methods of managing labor and delivery are discussed. Dr. David Grimes, in defending late term abortions in an article in JAMA, specifically mentions only Eisenmenger syndrome (but uses an out-of-date reference from l979, a time when cardiology was less advanced and when viability was later in gestation), conjoined twins (a question of fetal anomaly, not of maternal life), and a newly diagnosed large thoracic aneurysm (but if the fetus was viable, it would have made more sense to put the mother under anesthesia, deliver the baby by C/S, and then proceed to repair the aneurysm in a dual procedure). Hawkins and Elder in their chapter on Abortion Counseling discuss the British experience: "There are very few circumstances in which the continuation of a well managed pregnancy can be held to be a direct risk to life, in the sense that an obstetrician would advise termination of a wanted pregnancy. In carcinoma of the cervix diagnosed in early pregnancy, the conceptus succumbs to the treatment whether it is radiotherapy or surgery. In a very severe heart conditions such as Eisenmenger’s syndrome, in which confinement is commonly followed by a reversal of the cardiac shunt and maternal death, there is doubt if the risk following abortion is much less." They then mention the non- necessity of induced abortion in cases of renal or hepatic failure. " A life actually saved by therapeutic abortion is very rare- we recall a single case of status epilepticus coming on in early pregnancy which repeatedly failed to respond to therapeutic measures short of general anesthesia, and resolved after a therapeutic abortion." (If this had occurred after viability, the baby could have been delivered instead of aborted – my comment.)
The only article I found that specifically commented on delivery versus abortion after viability was a commentary in the British Journal of Obstetrics and Gynecology, June 1995, Vol 102, pp.434-435, titled, "Is third trimester abortion justified?" by Frank A. Chervenak and Stuart Campbell, professors of OB-GYN at New York Hospital-Cornell and Kings College of Medicine and Dentistry, London respectively and by an ethicist from Baylor, which in fact deals with post-viability rather than just third trimester abortions. They comment, "The risks of continuing a viable pregnancy to term are in almost all cases reasonable. In the rare instance in which the woman’s health necessitates delivery, all efforts should be made to help the child." I also have a personal e-mail from Dr. Gene Rudd, an obstetrician who is the Associate Director of the Christian Medical and Dental Association giving his reply to my request for information on whether killing a viable fetus is ever necessary to preserve the life of the mother. "Once the baby is old enough to survive outside the womb, the burden should be on the patient or doctor to prove that killing the baby is necessary to save the mother’s life. While this has been claimed, I and others who have looked at the cases are not aware of a case where this is so. There have always been good alternatives that attempt to preserve both lives."
Of the women who stood up with then President Clinton when he vetoed the partial-birth abortion ban claiming medical necessity, none actually had a condition requiring abortion to save her health or life. Some had fetal anomalies, but only one, a baby with hydrocephalus, would have posed any risk to the mother with vaginal or C/S delivery, and then only if delivery had been attempted without first draining off the excess cerebrospinal fluid. When I was a pediatric resident in the late 70s, the neurosurgeons did not like to place a shunt in babies with hydrocephalus until they were sure it was persistent, so we would blindly insert a needle through the fontanelle (soft spot) through brain tissue into the lateral ventricle of the brain and let the excess cerebrospinal fluid drip out. We would do this every day or two until the neurosurgeons became convinced that they needed to place a shunt. Scary as it was (this was in the months before 2-D ultrasound became available), the babies tolerated it well. Today, a baby with hydrocephalus and a head too large for safe delivery would be treated in a similar manner, though under ultrasound guidance and as a one-time procedure just before delivery. The baby can then be safely delivered without sacrificing either its life or its mother’s life.
The AMA states that except in extraordinary circumstances (none of which are specified) maternal health factors that demand termination of the pregnancy can be accommodated without sacrifice of the fetus (in the context of after viability).
One other thing to examine is the comparison of mortality rates for women from abortions after 20 weeks with mortality rates from childbirth. Actually, maternal mortality rates include not only mortality from childbirth, but also from spontaneous and induced abortions, ectopic pregnancies, and possibly from unrelated causes (it is not clear to me whether these are still included or not), so they are actually falsely elevated. Maternal mortality rate in the U.S is 6.7/100,000 (1 in 15,000); the Alan Guttmacher Institute reports the maternal mortality rate for abortions done at 21 or more weeks as 1 in 6000. Thus the short-term risk to a mother’s life from a post-viability abortion is more than double that from childbirth on the average. Why this is so will become apparent in the later discussion of methods of post-viability abortion.
HEALTH OF THE MOTHER
How about the mother’s health? One problem with "health" is that the Supreme Court has defined "health" so broadly that virtually every pregnancy could be said to adversely affect a woman’s health: for example, raising a child is far more expensive than an abortion (economic health), backache and urinary frequency are part of the third trimester (physical health), and dealing with a colicky infant, or contrary toddler or adolescent or just the hormonal changes of pregnancy is emotionally stressful (mental health). Leaving the legal world and returning to the real world, most of the discussion I have heard has focused on reproductive health and mental health. Hawkins and Elder do mention that abortion followed by surgery on unrepaired Tetralogy of Fallot improves future pregnancy outcomes; they do not discuss this in relation to late term abortions; ToF is usually repaired in infancy and early childhood; a case presenting in pregnancy would be most unusual. They also mention repair of (I presume) severe ureteral reflux to decrease the risk of urinary tract infections in pregnancy, but UTIs can be readily treated and repair then done prior to the next pregnancy.
Not in the medical literature, but given as testimony by non-medical personnel in past years at General Assemblies has been the claim that late term abortions are necessary to preserve a woman’s reproductive health. Actually the converse is true: late term abortions increase the risk for future children by increasing the incidence of cervical incompetence. This increases the risk for spontaneous abortions and premature deliveries. Uterine perforation is also a risk and has been linked to some maternal deaths. Abortions involving curettage (D&C and D&E) abortions also are linked to an increase in the incidence of ectopic pregnancies. Women with a previous abortion have a higher rate of eclampsia and pre-eclampsia (high blood pressure, protein in the urine and seizures) even than primagravidas do.
The old saying of limiting a woman to three Caesarian sections has long been abandoned with the safer low transverse incision. I personally have cared for the children of a woman who had six uncomplicated Caesarian sections. In the last seventeen years, the standard hospitalization for a woman after a Caesarian section has decreased from four days to 2 and a half days in our local hospital. Many go home as soon as women do after vaginal deliveries (48 hours).
The other non-socioeconomic maternal health factor often cited is mental health. When abortion on demand was not available, this was often used as a rationale for induced abortion. However, now that abortion is widespread, more information is surfacing about post abortion syndrome. While anecdotal reports abound, the confidentiality surrounding abortion makes long term follow-up of a controlled group impossible, and post abortion counselors see a self-selected group. The incidence is unknown; a recent study found an incidence of 1.4% but had less than a 50% response rate to the 2 year follow-up questionnaire. This yields a theoretical incidence of between 7 and 520 per 1000, a range so broad as to be meaningless. Some generalizations can be drawn, however. Those having abortion as young teens, women who are ambivalent about abortion, and women having abortions for genetic reasons (all over-represented in post viability abortions), and women having late term abortions in general are all disproportionately represented among women seen with the most severe post abortion syndrome.
Hawkins and Elder note that "Paradoxically, it is the normally well balanced patient with an acute reactive depression or anxiety state who benefits symptomatically by her ‘ mental health’ being restored after a legal abortion, rather than the chronic psychiatric patient, whose psychiatric status is often unchanged or even worsened by the operation."
In 1996, the British Medical Journal and in 1997, the Acta Obstetricia et Gynecologica Scandinavica published a government funded study examining all women of reproductive age in Finland over a seven year period which found that women who had had abortions were 3 1/2 times more likely to die in the next year as women who carried to term: from natural causes 60% more likely to die; from suicide six times more likely to die; from homicide twelve times more likely to die; and from the accidents four times more likely to die. Interestingly, overall women who had not been pregnant were intermediate, twice as likely to die as those who gave birth. A Danish study found that overall women with a history of abortion had a 50% higher rate of admission to psychiatric hospitals than did women who had live born children.
More recently, a study was done linking 1989 medical (California Medicaid) records for 173,000 women who either gave birth or had an abortion with medical records and death certificates for the next six years. It found that women who had state-funded abortions were 2.6 times more likely to commit suicide than women who delivered their babies. The average annual suicide rate for women who delivered was 3:100,000 women, compared to 7.8:100,000 women who had abortions, and a national average of 5.2:100,000 women, confirming the finding of the Finnish study that childbirth is actually protective. In addition, post abortive women were more than twice as likely to have had 2 to 9 treatments for mental health problems during those six years.
At least fifteen studies link induced abortion and subsequent alcohol and drug abuse, the most recent showing a 5-fold increase after induced abortion.
Thus current evidence all points in the direction that in the long run, induced abortion is more likely to cause or exacerbate mental health problems than it is to treat them.
HOW ARE POST VIABILITY ABORTIONS DONE?
- The most widely publicized method is variously known by the lay term "PARTIAL-BIRTH ABORTION" or by practitioners as "DILATION AND EXTRACTION (D&X)", "INTACT DILATION AND EVACUATION", or by the AMA as "INTACT DILATION AND EXTRACTION". I will use D&X for short.
- Method: first, the cervix is dilated over a period of three days with laminaria, a type of seaweed that expands as it absorbs water, or synthetic dilators may be used. Forceps are inserted through the endocervical canal to grasp a leg of the fetus and, if the fetus is not already in a breech position, to pull the baby into a footling breech position, a maneuver known as internal podalic version. The legs, trunk, and arms are then delivered, leaving the head of the baby inside the uterus. Pulling down on the living baby with one hand, the abortionist inserts scissors into the base of the skull, opens them, inserts a suction catheter into the cranium and suctions out the brain, killing the baby. The skull is then small enough to pull out, completing delivery of the dead baby. The placenta is then delivered.
- Acute maternal complications: there have been no controlled studies looking at complications from this procedure. However several risks are apparent. First, the risk of uterine rupture may be increased due to the internal podalic version, which also carries risks of abruption (partial separation of the placenta of from the uterine wall which can involve massive hemorrhage), amniotic fluid embolus, and trauma to the uterus. Williams Obstetrics says "there are very few, if any, indications for internal podalic version other than for the delivery of a second twin." Obstetrician Dr. Joseph DeCook points out that physicians abandoned this procedure over 30 years ago because of the risk involved.
In addition, inserting scissors blindly into the base of the skull carries the risk of injury to the woman’s cervix, causing severe hemorrhage. The complication of cervical incompetence will be discussed more fully under D&E abortions, but it should be noted that intact D&X abortions require a larger degree of cervical dilation than do D&E abortions.
- Dilation and Evacuation Abortions (D&E)
- Method: first, the cervix is dilated over a period of time, usually one to two days for a post-viability abortion. Forceps are inserted to grasp the fetus and the teeth are repeatedly opened and closed, crushing him or her until the tissues are soft enough to be pulled apart and removed piece by piece from the uterus. It is important to keep track of the fetal and placental parts as they are removed, so that none are left inside the uterus. Sometimes oxytocin is given to contract the uterus and decrease blood loss and to make it easier to distinguish fetal parts, but this also increases the risk of entrapment of fetal parts. If it is not obvious that the entire placenta and all of the parts of the baby were removed, the uterus is then scraped with a sharp curette to remove anything left.
- Acute maternal complications: as well as entrapment and retention of fetal and placental parts which will result in infection and continued vaginal bleeding, risks include perforation of the uterus either by the uterine sound, the curette or suction catheter, or by boney fragments of the fetus; disseminated intravascular coagulation, amniotic fluid embolus, intrauterine adhesions (up to 38% in one study after curettage in mid trimester abortions), trauma to the cervix and future increased risk of spontaneous abortion, premature delivery, and low birth weight. A study of rigid dilation of the cervix showed that increasing the dilation from 14 to 16 mm increased the incidence of low birth weight infants 2.5 fold, and the desirable minimum spread between the jaws of the forceps is up to three cm after 24 weeks gestation. Dilapan and laminaria may cause less cervical trauma than rigid dilators; a risk of Dilapan is fragmentation within the endocervical canal.
- Installation Methods – Hypertonic Saline
- Method: 35 to 200 ml of amniotic fluid is removed and 200 ml of 20-25% saline is injected into the amniotic sac. This usually kills the fetus within six to twelve hours and damage to cells within the uterus causes release of prostaglandins, which causes the onset of labor. Oxytocin may be used to augment labor. 20 to 46 hours later, a dead baby is delivered. Retained placenta may require surgical evacuation of the uterus from 15% to 28% of the time. On rare occasions, a burned baby may be born alive.
- Acute maternal complications: Other than retained placenta, inadvertent intramyometrial saline injection can cause necrosis of the uterine wall, hemorrhage requiring a blood transfusion; extravasation or intravascular injection can cause hypernatremia, convulsions, coma, and death. Disseminated intravascular coagulation occurs in all saline abortions and sometimes causes a massive hemorrhage. Cardiac failure, septic shock, and peritonitis are other complications. Conversely, oxytocin overdose can cause water intoxication. Because of the serious complications, saline abortions have decreased from 46% to less than 1% of abortions after 20 weeks gestation,.
- Installation Methods - Prostaglandin with or without Urea
- Method: Approximately 200 ml of amniotic fluid is removed by amniocentesis, followed by and intra amniotic infusion of 135 ml of 60% urea solution. This kills the fetus, but does not cause labor, so it is followed by augmentation with either oxytocin or prostaglandin. Oxytocin is given intravenously according to different protocols at 10 to several hundred times the dose used for labor induction or augmentation of a normal delivery. There are a number of different prostaglandins in use. They may be given directly into the amniotic sac, as a vaginal suppository, or as a gel placed in the endocervical canal.
- Acute maternal complications: incomplete abortions with placental retention occur between 10% and 47% of the time. Amniotic fluid embolus is a concern, although otherwise urea is less toxic to the mother then hypertonic saline. Use remains around 4%. Complications of prostaglandin will be discussed under labor induction methods.
- Direct Fetal Killing
- Methods: Either 1 to 2 mg of Digoxin is injected into the amniotic fluid or into the abdomen of the fetus without ultrasonographic guidance or KCl is injected directly into the baby's heart. The purpose of this when used in conjunction with D&E abortions is to soften the tissues making it easier to tear the baby apart; when used in conjunction with the labor induction methods, the purpose is to ensure a dead baby, making it clear that termination of pregnancy was not the real goal. While labor may spontaneously ensue, the risk of disseminated intra vascular coagulation increases with time, and this is used only in conjunction with one of the other methods of abortion.
- Acute maternal complications: Small enough doses are used that the only maternal complications reported have been transient bradycardia with digoxin.
- Labor Induction Methods
- Methods: as mentioned under urea/prostaglandin in fusion, high dose oxytocin and/or prostaglandins are used.
- Acute maternal complications: oxytocin can cause water intoxication. Prostaglandin can cause bronchoconstriction, cardiac arrhythmias, myocardial infarction, and hypertension even with intracranial hemorrhage. Less serious complications include a high incidence of incomplete abortion, and nausea, vomiting, fever, diarrhea, and hypersensitivity in up to 70% of the time. Some prostaglandins have been associated with uterine rupture and Cytotec’s manufacturer has warned obstetricians against this type of off-label use.
- Hysterectomy involves surgically opening the uterus and removing the baby; hysterectomy involves removing the uterus with the baby undelivered.
- Acute maternal complications: Why abortionists combine these two procedures into one category is beyond my comprehension. Hysterectomy during pregnancy involves dealing with hugely dilated uterine arteries and veins and large blood loss is common. When there is significant uterine pathology such as carcinoma of the cervix or large fibroids, it may be indicated. Otherwise, it higher complication rate makes it a rare procedure used less than 1% of the time.
In post viability abortions, the maternal mortality rate is about equal, around ten to fourteen per 100,000 abortions, for dilation and evacuation methods (Intact D&X is included as well as standard D&E in this category) and for labor induction methods. Fetal mortality is 100% with D&E methods, but when direct fetal killing is not used, labor induction methods can sometimes result in birth of a live baby. When a dead baby rather than termination of the pregnancy is the goal, this is looked upon as a complication and there are several articles in the literature recently discussing the ethics of how to handle this. This is also the reason for the push in Congress for the Born Alive Act.
It is hard to know how often each of these procedures is done. According to the CDC, 85% of abortions done after 20 weeks was by one of the curettage methods, 3.6% were by installation methods, 1% were by medical methods (labor induction?), and 10% were by other methods (does this included labor induction? Were some intact D&X abortions included? This category does include hysterectomy/hysterotomy procedures. This is the first year that medical methods are listed, so labor induction may well make up a large portion of "other".)
LONG-TERM MATERNAL COMPLICATIONS:
- Complications for future pregnancies: As mentioned above, methods that involve forcible dilation of the cervix, especially in primagravidas, increase the risk for spontaneous abortion and premature delivery in subsequent pregnancies, and methods that entail curettage (this would also apply to incomplete abortions in non-D&E methods) increase the risk for ectopic pregnancies (especially if there is concomitant infection, particularly with Chlamydia which is the second most common STD in the US today) and for uterine adhesions. Induced abortion in general has been shown to increase the risk of pre-eclampsia and eclampsia over that found in first pregnancies or in second pregnancies after live birth in the first pregnancy. A perforated uterus at times requires a hysterectomy. If the mother is Rh negative and Rhogam is not given, future children may be jeopardized by RH isoimmunization.
- Mental health complications have already been discussed.
- Breast cancer: 11 of 12 US studies and 25 of 31 study worldwide have shown an increased risk of breast cancer after induced abortion. Critics of the American studies claim that women who have breast cancer are more likely to admit to abortions than those who do not have breast cancer; however 1 US study was prospective, yet still showed increased risk. Critics of European studies showing no significant risk point out that these studies had critical methodological errors. The data was manipulated in such a way as to cancel out any effect seen. The largest study of Danish women both falsely assumed no abortions before 1973 (further investigation revealed 60,000), made an adjustment of 1.44 for cohort group (to correct for the rising rate of breast cancer; however if the increased rate of induced abortion in younger cohorts is why they have more breast cancer for their age, then this adjustment has effectively cancelled out the very correlation they are looking for), and also failed to report the raw data. Follow-up time on women who had abortions averaged less than half that of women who did not have abortions60. Overall, a meta-analysis of 28 studies published in 1996 showed an increased risk of 30% following induced abortion61. The United Kingdom’s Royal College of Obstetrician and Gynecologists has stated that this paper "had no major methodological shortcomings and could not be disregarded."
Why do induced abortions cause breast cancer?
Before pregnancy, the cells in the breast are in an immature form, with an average susceptibility to cancer. During the first two trimesters of pregnancy, they proliferate. In the last trimester they transform into mature cells. By the end of pregnancy, the mature cells abound and they have a low susceptibility to cancer (which is why women who have borne children have a lower risk of breast cancer than childless women.) Breast-feeding lowers this susceptibility even more. But during the period of proliferation and transformation, the cells are at their highest susceptibility to cancer. Induced abortion suddenly stops the changes in the breast at their stage of highest susceptibility. (Spontaneous abortion does not produce this risk because the lower estrogen levels associated with pregnancies that spontaneously aborts do not cause the same degree of breast changes.) The risk is highest in a pregnancy before a full term delivery (nullipara). The combination of family history of breast cancer plus teenage induced abortions is the strongest of all predictors of breast cancer in a woman.
Although the methodological flaws in the Danish study affect its conclusions on the overall risk of breast cancer following abortions in general, I do not think they adversely affect its findings on the risk of breast cancer relative to the timing of abortion: the risk steadily increased with duration of gestation, and was over 2 ½ times as high if the abortion took place after 18 weeks gestation compared to before 8 weeks, (and overall 90% higher than non-aborters though this figure freed from the statistical manipulations could be 30 to 40 percent higher). As far as I know, none of the other studies looked at gestational age (though I have not read all the studies).
This finding is of the utmost importance in considering the long term safety (or lack thereof) of post-viability abortions. One of eight US women will be diagnosed with breast cancer in her lifetime. Today, a quarter of these women will die of breast cancer. That means that 3% of women die from breast cancer. If induced abortion increases this risk by 30%, then nearly 1 in 100 women who has an induced abortion will later die as a result of it. If breast cancer is increased by 90% following abortions after 18 weeks gestation, then over 1 in 40 women who has a post-viability abortion will die of breast cancer and 1 in 10 women will develop breast cancer caused by the abortion. If the life of the woman or fetus demands premature termination of pregnancy in the late second trimester (by a method to preserve the life of the baby), will she also encounter this risk? No studies have been done, but physiologically, I would think so, unless she breast-feeds the baby (and pumping to keep up an adequate milk supply until the baby is mature enough to nurse is a real challenge), since lactation lowers her risk significantly. Therefore, the breast cancer risk is probably a moot point when the life of the mother is at stake, but it is very much a point to be considered when abortion is contemplated for fetal genetic of other abnormalities or for socioeconomic reasons.
FETAL FACTORS such as perception of pain during the abortion, etc. will be discussed after the discussion of abortions due to fetal abnormalities.
A second reason given for post viability abortions is the presence of fetal abnormalities. These can be divided into several categories:
- Those invariably fatal usually within a few minutes/hours/or days after birth such as anencephaly or Potter’s syndrome (lack of kidneys causing a lack of urine and inadequate amniotic fluid resulting in inadequate development of the lungs)
- Those invariably fatal, usually in a few months or years, such as Trisomy 13 or 18, or Tay-Sachs.
- Those causing long-term disability and significantly shortened life span such as Duchenne Muscular dystrophy,(teens), cystic fibrosis, and sickle cell disease (30s) in which cure or full control is not yet possible (actually bone marrow transplant will cure sickle cell disease, but it carries its own risks)
- Those with long term disability such as Down syndrome and spina bifida
- Those with relatively minor problems such as clubfeet, cleft lip or palate. Often these can be surgically repaired.
It is important to know that abortions have been done (Dr. James McMahon’s testimony before Congress) for reasons as trivial as cleft lip.
Caring for Families Experiencing the Early Death of a Child
It is often thought easier on the mother to abort a fetus who will die shortly after birth than to carry the baby to term, knowing that he won't live. I do not think this has ever formally been studied. But I think our experience with malformed children who are still born or die shortly after birth sheds a different light on this. For years it was thought kinder to parents to whisk away these children to save them the grief of seeing the malformations. But we have changed, and now we encourage the parents to hold their child and tell him or her of their love, and spend time alone with the baby. This allows them to grieve more completely, rather than bottling up their grief, and their healing is both faster and more complete. When the child is not still born, but lives for a few minutes or hours (or days: the first child I cared for with anencephaly went home with his parents at three days old and lived for twelve days, though subsequent patients with anencephaly have died within 30 minutes of birth), the time the parents have with the living child are precious. While this time is still a possibility with premature induced delivery, this cuts short the parents' intrauterine time with their child and the baby is less likely to survive labor and likely to survive a shorter time after delivery compared to waiting for the spontaneous onset of labor or induction at term. Abortion by a method that directly kills the child (D&X, D&E, saline or urea installation) eliminates the possibility of postpartum time with the living child.
When the parents wait on God's timing for the birth and death of their child, they have the comfort in their grief of knowing that they have done all possible for their baby rather than having the knowledge that they shortened his or her already brief days.
Women who abort for genetic or fetal abnormality reasons are among those will are most likely to suffer from post abortion syndrome.
In the long run, we are not being compassionate by encouraging or affirming women in aborting babies who will not survive. Ideally, when we know that a fetus has a lethal abnormality, it will be born after the natural onset of labor (or Caesarian section when necessary preferably under epidural / spinal anesthesia so the mother can be awake in case his or her survival is extremely brief). The pediatrician will dry off the baby, wrap her in a warm blanket, and hand her to the parents. Some parents will wish to have their baby baptized. Any other details like footprinting, weighing, etc can wait until the parents have had sufficient time with the baby. When it is known that the baby has a disorder that will shortly be lethal, there is no reason to subject him or her to any painful procedures. (When physicians do not know at birth that the baby has a rapidly lethal abnormality, the situation is different. Then the baby may well be subjected to painful procedures in the effort to diagnose him and save his life.)
B-E) Since the question your committees are dealing with is post viability abortions and the babies in A) are not viable, the above discussion is in some ways irrelevant, but in others it is quite relevant because many of the same principles apply to situations where abnormalities result in a period of disability before eventual death (whether in six months, 6 years, or 60 years). Arguments for abortion are made on two bases: prevention of suffering for the child, and prevention of the burden on the family. Suffering comes in two major forms: physical (primarily pain) and mental. Physical suffering can almost always be alleviated with proper medical treatment, though not always immediately. We don't like to admit it, but physical pain is not all bad. Not only are there the theological benefits as expressed by Paul in discussing his thorn in the flesh (not to infer that the thorn was necessarily physical), but Dr. Paul Brand eloquently describes the benefits of pain. Caring for leprosy patients for a quarter century in India, he learned that much of the disability of leprosy comes from injury due to the lack of pain. Just think how the reflex withdrawal of a hand from a hot stove prevents a major burn. Acute pain is a warning that something is wrong. Chronic pain, however, is disabling, but can be controlled if treated properly.
Mental suffering exacerbates physical pain but its treatment is not medical, though anxietiolytics occasionally have a role, as do, more often, antidepressants. Mental suffering is often caused by a feeling of isolation. We in the Christian community could do much more to alleviate mental suffering than we do. We in the PC(USA) talk about "So All May Enter" and that is important and good. But we can and should do more.
For the children, we should make an effort to include activities that they can participate in. We should take our healthy (when they do not have respiratory infections, etc.) children to visit children who can't get out.
Rather than excessive pity, we need to consider that what may seem to us to be a very poor quality of life (mental retardation, inability to walk, etc.,) may not seem that way to the child. Several recent studies have surveyed disabled youth and found that they consistently ranked their self worth and health quality of life as high or within 3 percentage points as high as non-disabled youth did. As a pediatrician, I have cared for many, many disabled children, and I think I can honestly say that in all these years, I have never seen one (who lived for more than a few weeks), even the most profoundly retarded, who did not demonstrate through his or her smile, a love of living.
Isaiah said of Jesus, " a bruised reed he will not break, and a dimly burning wick he will not quench…" (Is 42:3). Let us emulate him and not quench the dimly burning wick of our disabled children, even the most severely disabled and those with the shortest lifespans, but affirm and protect and nurture them before birth as well as after birth.
Parents of disabled children may suffer in many ways: from isolation, from financial burdens, from physical and mental exhaustion when their child requires constant care, and from empathy when their child suffers. We in the church can help bear each other's burdens in many ways from visitation to respite care to assisting with housework, raising funds to assist with medical and travel expenses not covered under SSI, CMS, Medicaid or insurance, and by prayer. The response of the local congregation to the McCaughey septuplets is a model of what the church can do. Parents need to know that we will be there for them and then we need to follow through on our promises. We need to encourage these parents spiritually.
While suffering produces endurance, and endurance produces character (Rom 5:3-4), God has promised that he will not burden us with more than we can bear (a liberal paraphrase of I Cor 10:13) and he will never leave us or forsake us. Although a disabled child may place a great demand on parents, and one that may persist for decades, a disabled child also gives a great deal, especially the teaching of unconditional love. Siblings of disabled children usually are far more loving and unselfish that children in general.
Does the clay say to the Potter, " Why have you make me this way?" We do not always understand God’s purpose in making children the way he does, but we know that he makes all things work together for the good of those who love him. Our church has said, " the birth of a severely disabled infant is not a time for mourning. No one has died."
But still there is a grieving period when parents learn that their child (born or unborn) is disabled: grieving for the loss of their dreams for a normal child. Yet we are routinely counseled against making major decisions during the acute phase of grief. No wonder abortions for genetic reasons have such a high rate of post abortion stress syndrome. Rather than acquiesce in the fear and despair of parents suddenly faced with the prospect of a "less than perfect" child, whether that child be mildly or profoundly mentally and/or physically disabled, let the church encourage their parents to accept what God has made and help them to love and care for each and every one of their children for as many days as God gives them.
I commend to your committees the Report of Task Force on Severely Handicapped Children reported to the 197th General Assembly (1985). It reads in part: "35. 446
The Program Agency and General Assembly Mission Board believes that every human being is a unique creation of God. It affirms that God's creation is good and reflects the image of the creator. It believes that God desires for all people lives that are dignified and purposeful. It is certain that it is the task of the church to offer a community in which all people can mature and realize their spiritual callings as co-creators with God."
EFFECTS OF ABORTION ON THE UNBORN CHILD – FETAL PAIN
Before leaving the subject of suffering entirely, it is appropriate to address the pain that the viable fetus endures during the course of an abortion. The center of pain in the brain is the thalamus, which is formed at the end of the embryonic period at eight to ten weeks gestation. Whether this is sufficient for deep pain we have no way of knowing because without cortical connections, there is no memory or good way to express pain. I do know that decorticate adults will posture in response to deep sternal pressure. The presence of a functioning cortex is not necessary to pain sensation. Even complete removal of the cortex does not eliminate the sensation of pain; no portion of the cortex if artificially stimulated results in pain sensation. Sensory nerves, including pain fibers (nociceptors) reach the skin of the fetus before the ninth week, and movement of electrical impulses between these fibers and the spinal column has been demonstrated. By thirteen and a half weeks, cortical connections with the thalamus have begun to form and the fetus will withdraw aversively, not just reflexively, from a painful stimulus.
The cortex began to form at 8 weeks and has its full adult number of neurons by 20 weeks. Vigorous fetal movements including flexion or extension of the trunk, flexion of the limbs and turning of the head have been observed in response to needlesticks in 12 to 16 week fetuses. Also at this age substance P, a tachykinin shown to have a role in the transmission of pain impulses, and its receptors, have been found in the spinal cord.
As gestation proceeds, synaptic connections increase and the fetus’s perception of pain increases. Doppler studies of fetuses at eighteen weeks gestation undergoing invasive procedures that involve penetration of the trunk show acute stress by blood flow redistribution to the brain73, and fetal hormonal stress response to needling of the intra-abdominal portion of the umbilical vein has been measured at 23 weeks gestation. (Younger fetuses were not tested.) Pain fibers form before inhibitory fibers form, and are much denser in the premature baby and infant than in the adult, so the late second trimester and early third trimester baby actually feels pain more severely than does a term neonate. Physicians and nurses are becoming more and more aware of the need to treat pain in the nursery. The Joint Commission On the Accreditation of Hospitals is now grading hospitals on how well they diagnose and treat pain in their patients. Tearing a fetus limb from limb, crushing the body, forcibly incising the cranium are all procedures that have to be excruciatingly painful. So also is the slow burning death of saline (mothers report feeling the fetuses thrashing around in the womb for a couple of hours) or urea infusion. Prostaglandins in doses given to induce abortion usually cause severe nausea in the mother and have at times caused myocardial infarction,. Do the fetuses also suffer from nausea and chest pain? I don’t know.
D&E abortions from 16 to 24 weeks and later are usually done under local anesthesia with sedation. There is no attempt at fetal pain control. Even under the anesthesia given the mother for Caesarian section, the baby feels pain. As a pediatrician, I am called to be present at the delivery of any of my patients by C/S. Half the time, the baby starts crying as soon as his head is delivered, even before he is officially born. The baby is not anesthetized. It is likewise evident that when the uterus was opened to repair Samuel Armas’ myelomeningocele that he was not anesthetized because he was awake enough to grasp the surgeon’s finger at 21 weeks gestation. (He was given further anesthesia before the repair itself was begun.)
There is no evidence that the embryo feels pain; there is increasing evidence of pain with increasing gestational age in the early fetal period; and by viability anyone denying that the fetus feels pain is on very shaky ground.
There is ongoing debate in this country about whether the electric chair comprises cruel and unusual punishment for the men and women convicted of the most horrible crimes, and it has been centuries since drawing and quartering criminals was outlawed for that reason. Why then do we allow a procedure that is in essence the same as drawing and quartering to be carried out on innocent fetuses?
SOCIAL AND ECONOMIC REASONS
There is very little to say medically here, except to point out that almost all the articles I read by abortionists on late-term abortions commented primarily on these reasons, mentioning the disproportionate number of young women, denial of or trying to hide their pregnancy, ambivalence about abortion, as well as cost and access factors as reasons for late-term abortions. They mentioned the increased emotional trauma of late-term abortions, and gave as one reason for D&E rather than labor induction methods the transfer of some of the emotional burden from the patient to the medical staff. As mentioned under mental health, youth and ambivalence about the abortion (as well as feeling coerced into the abortion) are all associated with increased post abortion syndrome. Fear of coercion can certainly be a factor in trying to hide a pregnancy.
An anecdotal report demonstrates this mindset in some parents: About 12 years ago my Sunday School class discussed abortion one Sunday. Like much of the PC(USA), opinions were widely scattered. One woman said, "If my 14 year-old daughter became pregnant (she was 7 at the time), first I’d make her have an abortion and then I’d kill her." While she was being facetious about the second threat, in further discussion she made it clear that she was completely serious about the first threat.
CONFLICTS OF INTEREST
There are two areas where abortionists who do peri/post viability abortions are involved in conflicts of interest: the use of fetal parts and determination of viability.
- Fetal parts. Our policy states disapproval of abortion for the purpose of obtaining fetal parts. However in some cases the very people who do late-term abortions are also the ones who sell (for a "processing fee") or use themselves the fetuses obtained for experimentation. Dr. Leroy Carhart said in front of the 2001 General Assembly’s Committee on Health and Social Issues that he did research on the fetal tissues he obtained. Is it not a conflict of interest to have someone who wants the fetus for its parts to be counseling a young girl who is ambivalent about abortion?
- The AMA came out in opposition to third trimester abortion (except in cases of serious fetal anomalies incompatible with life), when fetal survival is "a near certainty," but says that before that time the physician should determine the viability of a specific fetus using the latest available diagnostic technology because the time when viability is achieved may vary with each pregnancy.
There are several problems with this reasoning. First, instead of our common law that the defendant can be executed only if proven guilty beyond a reasonable doubt, the defendant (fetus) can be executed unless proven innocent (viable) beyond a reasonable doubt. Second, the best available diagnostic technology can make a guess at gestational age and weight, but cannot predict within those parameters (OK, add in gender and race if you are not afraid of being accused of sexism and racism) which babies are viable and which are not. And I can tell you as a pediatrician that their guesses at birth weight are often off significantly. Even after the baby is born, it is hard to tell. If he is limp and extensively bruised, his chances are less than a baby who comes out kicking and gasping. But the obstetrician or abortionist cannot predict even this ahead of time. See the section on viability for the statistics they can use to give the best predictions. If you leave it up to the person who makes a living doing abortions to decide if "this baby" is viable, he has a strong financial incentive against predicting it to be viable. This is a major conflict of interest. I will return to this later under my recommendations.
The vast majority of people oppose post-viability abortions, but God does not rule by opinion polls. I will leave it to others to argue that viability confers a different moral status on the fetus.
I cannot find any Scriptural basis for believing that God’s care and concern for children before birth is dependent upon the current state of medical technology. Does God give a 24 week American baby a higher moral status than a 24 week Bangladeshi baby because the American lives in a wealthier nation? Or a 22 week baby in 2001 a higher status than a 27 week baby in 1973? Rather the theme of God’s unchanging faithfulness runs throughout Scripture.
Where does Scripture address the viable fetus? Where does Scripture address the previable embryo of fetus?
- A) The only place I find where viable fetuses are unquestionably addressed is in Gen 38:27-30 where Zerah stuck his hand out during labor, drew it back after the midwife had tied a crimson thread around it, then his twin Perez was born first.
- I’ve always pictured Jacob and Esau fighting in the womb at the end of pregnancy (Gen. 25:25), but that is just my assumption, as Scripture does not specify when it was and it could have been at any time after quickening which can certainly occur before viability today and even more so then. So my guess is that it was after viability, but I don’t know that.
- Elizabeth was in her 6th month of pregnancy when the angel came to Mary and Mary conceived Jesus by the Holy Spirit. Mary then set out to visit Elizabeth and stayed 3 months, returning home before Elizabeth’s son John was born. This makes it clear that Mary’s arrival occurred when John was between 22 and 26 weeks gestation. And John, filled with the Holy Spirit, leaped with joy. Was John viable? Well, today a baby of that age is viable, but 2000 years ago there were no ventilators or IV hyperalimentation or other equipment needed to keep a baby born that prematurely alive. So back then he wasn’t viable, but he was filled with the Holy Spirit.
- Exodus 21:22-25 deals with the theoretical case of a pregnant woman who tries to separate two fighting men (I guess that is what she is doing) and goes into labor. There are different ways of interpreting what follows, and the question of viability depends upon the interpretation. Clearly she delivers and is no longer pregnant by the end of verse 22. But what was the gestational age of the child (Hebrew "yeled")? Was the yeled viable? The Talmud argues that it was not (or at any rate did not survive the injury and birth), and while this carries great weight, the Talmud, like our Book of Confessions, can and does err, and is not to be valued greater than Scripture itself. And what is the best interpretation of Scripture? Scripture itself. The Hebrew verb "yatso" is translated elsewhere as giving live birth (Gen 25:25-26; 35:11; 38:28-30; Ex 1:5; Deut 28:57; 2 Sam 11:16; 1 Chr 1:12; Job 1:21; 3:11; Ecc 5:15; Jer 20:18) though in Num12:12 it is used for the birth of a stillborn child. The Hebrew word usually used for miscarriage, "shakol" used in Ex 23:26 and Hos 9:14 was not used. Yeled is the usual Hebrew word for child (see also Ex 1:15-16); "nefel" translated as "stillborn child" in Job 3:16 and Ecc 6:3 or "untimely birth that never sees the sun" in Ps 58:8 is not used here. To me, this comparison with the way the same words were used elsewhere is convincing.
What is the significance of these various interpretations? If yatso-yeled includes the option of a live premature birth (or even term if she was "near her time" when the fight occurred) with survival of the child, then there is a fine imposed on the perpetrator for the worry he caused the family, but if either the woman or child suffer injury or death, then the perpetrator will be inflicted with the same. If yatso-yeled does not include the option of the survival of the child, then the perpetrator is fined for the death of the child and is inflicted with the same injuries as the woman suffered. Compare this to Num 35:9-15; 22-25 where manslaughter is punished by protection in cities of refuge until the High Priest dies – a minimum security jail term, so to speak. But if the person he accidentally kills is a pregnant woman who gets in the way of a fight, then his punishment is death – and this is clear under either interpretation. Isn’t that amazing- that God should give such protection to the woman with child! And if the live premature birth option is a valid interpretation, then accidentally killing a fetus deserves even greater punishment than accidentally killing a grown man. If the miscarriage interpretation is correct, then which is a greater punishment: a fine or having to live in the city? (I think that would depend on how much the fine was, how nice the city was – certainly it was safer from marauding armies than the countryside; whether he went from being an independent farmer to a beggar or whether he was a man of business who would thrive in the city, etc.)
- Jer 1:5. "Before I formed you in the womb I knew you, and before you were born I consecrated you; I appointed you a prophet to the nations." Certainly the knowing was pre-viability; in fact, before the fetal period began since the basic formation of the human takes place between 2 and 8 weeks gestation. If "before I formed" means "before I started forming" then God’s knowing Jeremiah refers to his zygote-blastocyst stage. Whether the consecration as a prophet was pre- or post-viability is not specified.
- Psalm 139. God speaks of knowing David completely from the time of his unformed substance (that’s the first 2 weeks of gestation)83 to the time he writes the psalm; and even testifies that God had written in His87 book all of David’s days before any of them yet existed.
- The only Scripture I can find that would differentiate between a time prenatally and a later prenatal time (or post-natal time as far as that goes) is in Gen 9:4-6, "you shall not eat flesh with its life, that is, its blood. For your own lifeblood I will surely require a reckoning; I will require a reckoning for human life. Whoever sheds the blood of a human, by a human shall that person’s blood be shed; for in his own image God made humankind." Blood begins forming in the embryo at 18 days after fertilization (when the mother’s period is 4 days late) .
- Jesus came to us first as an embryo, and it was in the zygote-blastocyst-up to 4th week of gestation embryo before even primitive reflexes form that John responded to His presence inside Mary and Mary’s status as His mother by leaping for joy. (Luke 1:41-44)
In summary, we are to love the Lord our God with all our heart and soul and might; to worship the LORD our creator who made us and not we ourselves, the one who bought us with His own blood. Therefore, we are not our own; we do not own ourselves and we do not own our bodies and we do not own our children either before or after birth: they are God’s. God’s care for the weak and helpless is pervasive throughout Scripture; we are told that whatever we do for one of the least of these, the sisters and brothers of Jesus, we do unto Him. (Do we really want to abort Jesus – pre- or post- viability?) We are commanded to love our neighbor as ourselves and to bear one another’s burdens. Can we not covenant together to care for both mother and child? To care for the whole family including the "unwanted" or burdensome or socially- embarrassing or disabled child? Does God require any less of us?
I hope that this paper is of some use to you in your deliberations. If you have any questions or there is anything I can help you with, please ask. May God guide you.
Patricia Lee June, M.D.
In many ways, terminology reflects philosophy and nowhere is this so apparent as in the controversy over induced abortion. Therefore I think it appropriate to define terms used in this paper along with some closely associated terms.
ABORTION: "The giving birth to an embryo or fetus prior to the stage of viability at about 20 weeks of gestation (fetus weighs less than 400 gm.) A distinction is made between abortion and premature birth: premature infants are those born after the stage of viability has been reached but before full term. Abortion may be either spontaneous (occurs from natural causes) or induced." This definition from Stedman’s Medical Dictionary points out an obvious conflict in the concept of an induced post-viability abortion, but the term "abortion" (actually, "induced abortion") is also used when a fetus is intentionally killed after viability.
SPONTANEOUS ABORTION: Abortion from natural causes, in lay terms, "miscarriage".
INDUCED ABORTION: "Abortion brought on purposely by drugs of mechanical means."
TERMINATION OF PREGNANCY: The ending of a pregnancy by natural or artificial means at any stage of gestation, whether resulting in live or dead offspring (or very rarely by the death of the gravida undelivered). The majority of pregnancies, which do not spontaneously abort in the first 2 weeks, are terminated by the spontaneous vaginal delivery of a living child at term. Others are naturally terminated by preterm labor and delivery or by spontaneous abortion, or are artificially terminated by induction of labor at term or preterm, or by Caesarian section (C/S) at term or preterm, usually resulting in a living child, or by induced abortion. Using "termination of pregnancy" to apply only to induced abortion is inaccurate and is not used in that way in this paper.
PREMATURE DELIVERY: Delivery of a child between the 20th and end of the 37th week of gestation.
GESTATION OF PREGNANCY: There are 2 ways of timing gestation, which can result in a great deal of confusion as the method is often not stated:
- From fertilization (conception). This is used by embryologists and actually is the true age.
- From the first day of the mother’s last menstrual period. This is the method used by obstetricians since the actual day of fertilization is rarely known. On the average, this adds 2 weeks to method a. Since premature births and abortions are dated using this method, it is the method that will be used in this paper unless specifically stated otherwise or unless I am quoting another source and they do not specify which method they are using.
CONCEPTION: Like the timing of gestation, this is a word that today has incompatible definitions. Historically, it means the fertilization of the ovum; the formation of the zygote (the first one-celled stage of an organism), and so Stedman’s Medical Dictionary defines it ("the fecundation of the ovum"; fecundate is defined as "to impregnate; to fertilize"), and so most people understand it. However, in the 1960s researchers chose to redefine "conception" to mean "implantation" in order to be able to use "contraceptive" to refer not only to agents that interfere with fertilization, but also to those interfering with implantation. This makes the use of the term "conception" in a formal paper difficult as it may be understood by author and reader differently. Using terms whose meaning has not been subverted will avoid the problem, and so I used "fertilization" in my defining of gestational age; nevertheless, "conception" comes more naturally to mind and voice and hand, so I need to make it clear that when "conception" is used in this paper, I use it in its popular and traditional medical meaning of "fertilization".
EMBRYO: Greek term used medically for offspring from fertilization until the end of organogenesis (when all the organs have been formed, at least in rudimentary form). In humans the embryonic period ends at the 8th week (method a). In the first week of the embryonic period, the embryo has more specific names: zygote (one-cell), morula (cluster of cells), blastocyst (hollow ball with a cluster of cells at one end – it is at this stage that the embryo implants).
FETUS: Latin term (meaning "young one") used medically for offspring from the end of the embryonic period until birth.
CHILD: " an unborn or recently born human being: FETUS, INFANT, BABY" – This is the first definition given for "child".
GRAVIDA: woman who is pregnant. Primagravida: woman during her first pregnancy. Multigravida: woman during a pregnancy after her first.
QUICKENING: when the mother first recognizes the movement of the baby in the uterus; it occurs earlier in subsequent pregnancies and in thin women. Occasionally women present at full term with unrecognized pregnancies in labor, claiming not to have felt the baby move!
-PARA: a woman who has given birth ----- times: Nullipara: a woman who has not yet given birth (primagravidas are by definition nulliparas, but a nullipara may also be someone whose first child/previous children were aborted either spontaneously or intentionally). Primipara: woman who has given birth once. Multipara: woman who has given birth more than once. Parous: Having given birth.
N.B. It is interesting that some people object to the use of the English terms "child" or "baby", insisting on proper medical terminology of "fetus" (though often incorrectly applying "fetus" to the embryonic period as well), while never using the proper medical terminology of "gravida" to apply to the mother of the fetus/embryo. This is inconsistent. Actually, like English, the Biblical Hebrew and Greek terms of "yeled" (Ex 1:15) and "brephos" (Luke 1:44; Acts 7:19; 2Tim 3:15) apply both prenatally and postnatally. I have yet to see an English translation of the Bible that uses "fetus" rather than "child", "baby", or "babe" to refer to John the Baptist (Luke 1:44) or Jacob and Esau (Gen 25:25-26) prenatally. Among medical personnel, both English and Latin terms are used freely and interchangeably, though the Latin is used more in journals and theoretically and the English more verbally and when referring to a particular individual. When an obstetrician calls me to discuss the timing or method of delivery, he usually refers to "fetal heart tones" and to "the baby". In this paper I will use both Latin and English terms freely and interchangeably.
NEONATE: Newborn (birth to 28 to 30 days)
PERINATAL: Around the time of birth; it includes the period both shortly before and shortly after birth.
VIABLE: "having obtained such form and development of organs as to be capable of living outside the uterus". This definition does not specify any particular length of survival. The Supreme Court defines viability as "The capacity for meaningful life outside the womb, albeit with artificial aid" and not just momentary survival.
CASE HISTORIES WHERE TERMINATION OF PREGNANCY WAS NECESSARY TO SAFEGUARD THE MOTHER
Case 1. In May 1995 Clarissa was a 17 year old secundogravida. Her first child had been stillborn. By 24 to 25 weeks gestation her blood pressure was severe enough at 164/116 that continuation of the pregnancy was risky to her health. The baby was severely growth retarded due to placental insufficiency caused by the hypertension and her survival was also in jeopardy, either if the baby was left in the uterus or if she was delivered. On May 5, an emergency C/S was done. Clarissa quickly recovered and went home a couple of days later (and became pregnant again within a few months, this time delivering a full term healthy boy). Akiya weighed only 397 grams (14 ounces) at birth, about the average weight of a 21 week gestation baby. After initial stabilization I transferred her to our regional perinatal center where she had a very rocky first few months. She went home still on oxygen, but has just completed her first month of first grade (regular classes). She's still small for her age, but healthy; in fact I have only seen her about once in the past year.
This case points out several issues: 1) If Clarissa had had no prenatal care, Akiya would have been predicted by ultrasound to be 21 weeks gestation (if her weight had been accurately predicted). Her viability would have been estimated at under 5%. 2) The emergency C/S effectively terminated Clarissa’s pregnancy and resolved her pregnancy induced hypertension while preserving her reproductive health and Clarissa recovered rapidly from the surgery. Actually, now that I think about it, all of the mothers that I can recall that had emergency C/Ss in our hospital in the second trimester have recovered quickly and were able to leave the hospital within 48 hours. 3) Akiya received a chance to survive, and in fact did survive and is now a small but otherwise normal 6 year old. (No, we do not intentionally deliver second trimester babies in our Level II hospital; only when it is not felt safe to take the time to transfer the mother before delivery.)
Case 2. The week before I started writing this paper, Connie started bleeding profusely at 34 weeks gestation due to a placental abruption. A stat C/S saved her life though she lost 2/3rds of her blood. Her baby, Annie, required ½ hour of oxygen but then did well. Neither Connie nor Annie would have survived the delay associated with dilating her cervix for either a vaginal delivery or an abortion procedure. This would also have been true had Annie been 20 or 30 or 40 weeks gestation. Now, three weeks later, both Connie and Annie are doing well.
1) CDC 97 stats Dec. 2000 p.___ Morbidity & Mortality Weekly Report Centers for Disease Control Abortion Surveillance-United States, 1997 Vol 49 NO 55-11 Dec. 8, 2000 p.1
2) Facts in brief: Induced Abortion Alan Guttmaches Institute; NY, NY 2001
3) STENBERG, v. CARHART United States Supreme Court Amicus Brief February 28, 2000 No. 99-830 BRIEF AMICI CURIAE of Association of American Physicians and Surgeons, Illinois State Medical Society, Physicians Ad Hoc Coalition for Truth, Christian Medical and Dental Society, Catholic Medical Association, Physicians Resource Council of Focus on the Family, Pennsylvania Physicians Resource Council, Physicians Research Council of the Indiana Family Institute, New Jersey Physicians Resource Council, Oklahoma Physicians Resource Council, Texas Physicians Resource Council, Wisconsin Physicians Resource Council, Drs. Kathi A. Aultman, Gerard Black, Watson A. Bowes, Joseph M. Casey, Byron Calhoun, Steven Calvin, William F. Colliton, Jr., Curtis Cook, Peter R. DeMarco, Fred de Miranda, Eugene F. Diamond, Timothy Fisher, Don Gambrell, Joseph R. McCaslin, Phillip McNeeley, Phillip Mets, Robert Orr, Edmund Pellegrino, Nancy Romer, Pamela Smith, LeRoy Sprang, Dennis D. Weisenburger, and Joseph R. Zanga, IN Amicus Brief Fianelli DM. Bill banning partial-birth abortions goes to Clinton, American Medical News. April 15, 1996:9, 10. P.27
4) Ibid; Statement of representative Charles T. Canady (R-Fla). Congressional Record; July 24, 1996 quoted in Sprang, p.74
5) Cunning Ham FG et al ed. Williams Obstetrics. NY NY: McGraw - Hill;2001 p.869
6) Danforth’s Obstetrics and Gynecology 8th ed. 1999
8) Gelber M, Sidi Y, Gassner S, Ovadia Y, Spitzer S, Weinberger A, Pinkhas J. Uncontrollable life-threatening status asthmaticus—an indicator for termination of pregnancy by cesarean section. Respiration 1984:46(3):320-2
9) Bowers CH, Chervenak JL, Chervenak FA. Late-second-trimester pregnancy termination with dilation and evacuation in critically ill women. J Reprod Med. 1989;34:880-883 see comment on Appendix B as to dates of publication.
10) Williams Obstetrics p. 869
11) Williams Obstetrics pp. 1192-1195;1216-17
12) Grimes DA The continuing need for late abortions JAMA 1998;280:747-750 pp 239-240
13) Hawking DF, Elder M. Human Fertility Control, Theory, and Practice. London, England: Butterworths; 1979:237-260 Ch 12 Abortion Counseling
14) Chervenak FA, McCullough LB, Campbell S. Is third trimester abortion justified? Br J Obstet Gynaecol. 1995 Jun;102(6):434-5
15) Romern Physician Ad Hoc Coalition for Truth (PHACT) congressional Press Briefing, July 24, 1996
16) Gans Epher JE, Jonas HS, Seckinger DL. Late. Term abortion. JAMA 1998;280;724-729
17) See Reference #2
18) Hawking & Elder p.241 (see 13)
19) Golan A, Barman R Wexler S, Langer R, Bukovsky I, David MP. Incompetence of the uterine cervix. Obstet Gynecol Surv. 1989;44:96-107.
20) Gans Epner p.727 Hawking & Elder p. 255 William p. 877
21) Williams p. 872-873 Amiouspith Sprang p.746 Castadot RG. Pregnancy termination: techniques, risks, and complications and their management. Fertil Steril. 1986;45:5-17
22) Hogue CJR, Cates W Jr, Tietze C., The effects of induced abortion on subsequent reproduction. Epidemiol Rev. 1982;4:66-94 Hawkins & Elder p. 253 Williams p.877 T. Strahan, "Induced Abortion as a Contribution Factor in Maternal Mortality or Pregnancy-Related Death in Women," Research Bulletin, 10(3):7, Nov-Dec 1996
23) D. Campbell et al., "Pre-eclampsia in second pregnancy," British Journal of Obstetrics and Gynaecology, 92:131-140, 1985. Quoted in Sobie AR The Risks of Choice. The Post Abortion Review. 2000; 8:3.
24) Major B in Archives of General Psychiatry Aug. 2000
25) Reardon DC, ed. Who is most at risk? Hope and Healing Elliott Inst, Springfield IL 1998 p.4
26) Hawking & Elder p. 241
27) M. Gissler, et.al., "Suicides after Pregnancy in Finland: register linkage study," British Medical Journal, 313:1431, Dec. 7, 1996 Gissler, M.,et.al., "Pregnancy-associated deaths in Finland 1987-1994 definition problems and benefits of record linkage," Acta Obstetricia et Gynecolgica Scandinavica 76:651-657 (1997).
28) H. David, N. Rasmussen and E. Holst, "Postpartum and Postabortion Psychotic Reactions," Family Planning Perspectives, 13(2), March/April 1981, p. 8892
29) Reardan, D Suicide Rate Higher After Abortion The Post Abortion Review 2001;9:6.
30) P. Coleman and D. Reardon, "State-Funded Abortions vs. Deliveries: A Comparison of Subsequent Mental Health Claims Over Six Years," poster presented at the 12th annual meeting of the American Psychological Society Miami Beach, FL June 2000
31) GansEpher p.729 Haskell WM, Easterling TR, Lichtenberg ES Surgical Abortion After the First Trimester in Clinician's Guide to Medical & Surgical Abortion. 1999; pp123-138 Amicus p7-8 Sprang p744
32) Amicus pp.7,16 Romer p.3 Epner p.7,26 Sprang p. 744 Cunningham FG, MacDonald Pc, Gant NF, et al, eds. Williams Obstetrics. 20th ed. Stamford, Conn: Appleton & Lange; 1997:507 in Amicus & Sprang
33) Haskell pp. 123-135.
34) See 36 Amicus p. 12 Castadot p.11 Haskell p.124
35) Lurie S, Appleman Z, Katz Z. Curettage after midtrimester termination of pregnancy: is it necessary? J Reprod Med. 1991;35:786-788
36) David A. Grimes, Kenneth F. Schulz, Morbidity & Mortality from second trimester abortions p.511pp.505-514 The Journal of Reproductive Medicine Volume 30, No 71 July 1985
37) Haskell p. 128
38) Williams p.872 Haskell p.128
39) Castadot pp.9-10 Blumenthal PD, Castleman LD, Jain JK Abortion by Labor Induction in Clinicians 33 1999;pp.139-154
40) Williams p.875 Castadot p.10 Blumenthal p.143-144
41) Castadot p.10 Blumenthal p. 143-144
42) Morbidity & Mortality Weekly Report, Centers for Disease Control Abortion Surveillance-United States, 1982-1983 Vol36 No 155 1987 p.4055 Abortion Surveillance 1997 p.43
43) Morbidity & Mortality Weekly Report, Centers for Disease Control Abortion Surveillance-United States, 1982-1983 Vol36 No 155 1987 p.4055 Abortion Surveillance 1997 p.43
44) Castadot p.10 Blumenthal p.144
45) Williams p.874; Castadot p.10 Blumenthal p.144-145
47) Williams p.875 Castadot p.11 Haskell p.125 Blumenthal p.144
48) Haskell p.131 Blumenthal p.150
49) Haskell p.131
50) Blumenthal p.150 Castadot p.10 (with urea)
51) Blumenthal p.143,145-147, Haskell p.225
52) Williams p.874 Castadot p.12 Blumenthal p.143-145
53) Williams p.875-876 Blumenthal p.143-145
54) Gans Epher p.727
56) Castadot p.12 Blumenthal p.150; Brind J Abortion and Breast Cancer: Additional Evidence of Link somehow not appearing in Published studies NRTL NEWS Nov 13, 1998 pp.20-21
57) Melbye et al (1997) N Engl J Med 336:81-5 Induced abortion and the Risk of Breast Cancer
59) Brind JP Danish defense: Does it make sense? Abortion Breast Cancer Quarterly Update 1997 pp.3-8 Melbye p.81-5
60) Brind and Chinchilli letter. NEJM 336:1834
61) J. Brind et al., "Induced abortion as an independent risk factor for breast cancer: a comprehensive review and analysis," J. of Epidemiology and Community Health, 50: 481-49.
62) Daling JR, etap risk of breast cancer among young women: relationship to induced abortion. J Natt Cancer Inst 1994;86:1584-92
63) Talk given to the Christian Medical Society at Emory University School of Medicine between 1973 and 1975; he has since written about this in numerous articles & books, and I think I again heard him discuss it at the MBF conference in Atlanta or Houston around 1986 to 1988
65) Saifal S et al self-perceived Health Status and Health-Related Quality of Life of Extremely Low Birth Weight Infants at adolescence JAMA 1996;276:453-459. King GA, Shultz IZ, Steel K, Gilpin M, Cathers T. Self-valuation and self-concept of adolescents with physical disabilities. Am J Occup Ther. 1993;47:132-140 Appleton PL, Minchom PE, Ellis NC, Elliott CE, Boll V, Jones P. The self-concept of young people with spina bifida: a population-based study. Dev Med Child Neurol. 1994;36:198-215
66) Program Agency PC (USA) Report of Task Force on Severely Handicapped Children 197th General Assembly (1985)
67) Collins VJ et al Fetal Pain and Abortion: The Medical Evidence 1984:1-11 Halliday, A.M., Logue V.: Painful Sensations Evoked By Electrical Stimulation in the Thalamus. In: Neurophysiology Studied in Man, G.G. Somjen, ed. Amsterdam: Excerpta Med., 1972, pp.221-230
68) Colling p.7
69) Guyton, A.C.: Textbook of Medical Physiology. Philadelphia: W.B. Saunders Co., 1976, p.666. "Indeed there seems to be little evidence that pain information reaches the sensory cortex." Patton. H.D., Sundsten, J.W., Crill, W.E., Swanson, P.E., eds.: Introduction to Basic Neurology. Philadelphia: W.B. Saunders Co., 1976, p. 198 Patton, H.D.: Somatic Sensation and Its Disturbances. In, Patton, H.D., et al., pp. 188-193
70) Collins, V.: Principles of Anesthesiology. Philadelphia: Lea & Feber, 1976, pp. 906-934
71) Westin, B., Nybreg, R., Enhoring, G.: A Technique for the Perfusion of the Previable Fetus. Acta Paediatrica, 47:339,1958
72) Anand KJS, Hichey PR Pain & its Effects in The Human Neonate & Fetus. NEJM 1317:1321-29
73) Sprang p.745
74) Sprang p.745
75) Anand pp.1322-23
76) Collins p.9
77) Gans Epner p.726 Haskell pp. 125
80) Carhart, Grimes, Blumenthal, Hawkins & Elder, Castadot, for example GanEpner 729
82) As someone who does not know Hebrew I am indebted to J.J. Davis in Abortion and the Christian Presbyterian & Reformed Publishing Co. Phillipsburg NJ. 1984 pp.49-51, 114 for first bringing this to my attention, NKJV notes and NRSV were used in verifying Scripture references. I realize that many do not capitalize pronouns referring to God the Father or to Jesus. In this paper I have tried to accommodate the weakness of my brothers & sisters in Christ for whom the first or second (depending on the dictionary) definition of "man" as "human being" is a problem by using the NRSV; I ask your graciousness in accommodating my weakness, for having been taught as a child to capitalize pronouns referring to God as a sign of respect for Him, I cannot help but feel disrespectful when I fail to do so.
83) Moore KL, The Developing Human: Clinically Oriented Embryology. WB Saunders Co. Philadelphia. 1974 pp.25-41
84) Moore p.49
85) Grimes DA Morbidity and Mortality from Second Trimester Abortions. J Reproductive Med. 1985;30:505-514
86) Muraska SJK et al Survival of a 280 g infant NEJM 1991;324:1598-9.
87) MacDonald PC et al. Williams Obstetrics 19th Ed. Norwalk Conn. P.855
88) Stedman’s Medical Dictionary, Williams and Wilkins Co. 21st ed, Baltimore 1966 p.3-4
89) Webster’s Third New International Dictionary of the English Language Unabridged. Merriam Webster, Chicago, 1986. P.389, p.2548