When abortions come late in a pregnancy
Though rare, most aren't for medical reasons
BY MARIANNE LAVELLE
Next month, Congress will attempt another vote to ban the "partial-birth" abortion, a procedure so disquieting that even pro-abortion-rights Democrat Sen. Daniel Patrick Moynihan has described it as "too close to infanticide." Used in pregnancies too advanced to be terminated by suction, the procedure (technically called "intact dilation and extraction," or "D&X") involves bringing the fetus feet-first into the birth canal, puncturing its skull with a sharp instrument, and sucking out its brain tissue through a catheter.
Those hoping to ban the procedure need three more votes in the Senate to override President Clinton's October veto. But no matter how the vote goes, the surrounding debate has already focused public attention on abortions that happen later in pregnancy--a small subset of terminations.
The politicized rhetoric of the debate, however, has done little to illuminate the complex reality inside abortion-clinic operating rooms. To get a better sense of this reality, U.S. News reporters called 31 of 79 clinics in America that provide abortions after 20 weeks of pregnancy. (That's the point at which most women can feel movement of the fetus, which is too large to remove from the womb by suction yet too undeveloped to survive outside it.) Eighteen of the clinics contacted, or more than one fifth of those performing abortions after 20 weeks, agreed to in-depth interviews.
Relatively rare. What the clinics told U.S. News supports some assertions long made by abortion-rights groups--in particular, that late (post-20-week) abortions are relatively rare. Only about 5,500 of the approximately 79,000 abortions performed by the clinics that responded (or 6.9 percent) were on post-20-week fetuses. (This is higher than the 1 percent found in national studies, because late procedures are concentrated at these few clinics.)
But the survey undermines another claim sometimes made by abortion-rights groups, at least with regard to the D&X issue: that late abortions are usually done for medical reasons, particularly to protect the life and/or health of the mother. Only 9.4 percent of late abortions at clinics that responded to the U.S. News survey were done for medical reasons, either to protect the mother's health (a rare situation) or, more commonly, because of fetal defects such as spina bifida and Down's syndrome (box, Page 32). For the handful of very late abortions, those after 26 weeks, medical reasons do predominate. But for post-20-week abortions generally, about 90 percent were classified by the clinics as "nonmedical."
These nonmedical abortions fell into several categories. "Our biggest group is 10-to-18-year-olds in total denial," says an official at one Southern clinic, making a common observation. Another category consists of women who find out late that they are pregnant: very young teens with irregular menstrual periods and women in their late 40s who mistakenly thought they had entered menopause. In interviews with 1,000 abortion patients, University of Alabama sociologist Michele Wilson found that compared with women who had abortions in the first trimester, those getting later abortions were more likely to be young, to live with their parents, and to have conferred with them on this decision. She concluded that some of the abortions were performed later because the women had to take more time to build family consensus for the choice.
Another surprising finding from the U.S. News survey is that the "partial-birth" procedure is neither common nor the most potentially controversial method clinics employ to terminate later pregnancies. Only three of the 18 clinics that responded reported doing D&Xs. Far more widely used is the procedure known as dilation and evacuation (D&E), in which the fetus is cut into pieces with serrated forceps before being removed bit by bit from the uterus. "If people object to D&X," says the director of one clinic, "what will they say when they get to this? D&E is the next battleground."
What also has escaped notice is the distinction between how the fetus is killed and how it is extracted. In most post-20-week abortions performed by clinics U.S. News interviewed, physicians first kill the fetus by cutting the umbilical cord or injecting digoxin (a heart medication) or other lethal agents to stop the fetal heartbeat. Then the fetus is removed, either intact (using a D&X procedure) or in pieces (using D&E). But one of the three clinics that use the D&X approach and four that perform the D&E dismemberment procedure do not kill the fetus first. The legislation banning "partial-birth" abortions would prohibit the live-fetus operations done by D&X but not those done by D&E. Physicians who do not kill the fetus first argue that their method is safer for the mother. Dennis Christensen of the Madison (Wis.) Abortion Clinic adds that "the fetus is not developed far enough to appreciate pain."
Moral qualms. How and when an abortion takes place are matters of little importance to the staunchest defenders of abortion rights and opponents of abortion. The former believe that a woman's right to choose is paramount, the latter that any abortion is murder. Yet polls show most Americans, while in favor of legalized abortion, feel that later abortions are more morally troubling.
Even abortion-rights advocates are beginning to say that late abortions pose special problems. Compared with early abortions, post-20-week procedures are four times more costly, seven times more likely to lead to medical complications, and far more physically and emotionally traumatic to the woman. In recognition of these problems, more and more clinics are offering counseling before the abortion. "I don't want laws to stop abortion at 20 weeks," says Charlotte Taft, an abortion counselor and consultant in Santa Fe, N.M. "But I'd like us to consider how we, as a society, can take responsibility for the denial and ambivalence" that lead to late abortions.
Taft recalls visiting a clinic in France that was using the abortion drug RU-486 for most of its procedures. "One doctor said that, `In France, we think that abortion is more moral earlier,' " Taft remembers. "And I thought to myself, we think so too in the United States, but we don't dare say it."
With Paul Glastris, Michael J. Gerson, Missy Daniel, and Michele Meyer
An excruciating decision over a dying fetus
Although the U.S. News survey of abortions after the 20th week concluded that they are infrequently performed for medical reasons, there are some cases--especially in the third trimester--where the fetus faces severe complications, which can even threaten the health of the mother.
Angela Browne-Miller was one such case. By the eighth week of her pregnancy in 1989, Browne-Miller could tell that something was wrong. Then 36, the San Francisco-area psychotherapist had already given birth to one child, and this felt different--like "something unrecognizable was going on inside of me." Six months into the pregnancy, an ultrasound showed the fetus had no lungs, no kidneys, an enlarged head, a double spinal cord, and cysts on the brain. The fetus had no chance of survival. Browne-Miller's doctors told her she had to abort the pregnancy or risk her own life.
Six years earlier, Browne-Miller had aborted what she believed was a healthy fetus because her husband-to-be said he was not yet ready to start a family. Yet this time she was determined to keep the child. Even as her fever rose and her doctors assured her the baby was as good as dead, she resisted. She felt bound to the life she had held in her womb for more than six months. "I wanted it to die a natural death," she says. Finally, facing pressure from family and friends, she agreed to the procedure.
After the operation, Browne-Miller returned to her normal schedule. But even as she saw patients, taught classes, and resumed her Silicon Valley consulting practice, she felt empty. "I was the only one who could grieve for this baby because I was the only one who had come to know it," she says.
Browne-Miller's experience and the stories she had heard from many of her patients led her to examine the idea of being free to choose and inspired her to write How to Die and Survive (Truthseekers Inc., 1997, $27.95), a book intended to help people cope with death, grieving, and the decision to terminate a life. "Women frequently feel pressured to have an abortion simply because it's so easy to do," she explains. Rarely, she says, are they prepared for the emotional toll the decision may have on them.--Elise Ackerman
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