Abortion Methods: Dilation & Curettage (D&C Abortion)

What is a D&C?

A D&C is a dilation & curettage. The cervix is dilated and a long, sharp, spoon-shaped instrument called a curette is used to scrape the inside of the uterus. Sometimes a D&C is done after a baby dies in a miscarriage but the woman does not go into labor on her own. Other times, a D&C is done to take a sample of uterine tissue to diagnose problems like polyps or fibroids. A D&C abortion may be done up to 13 weeks after the woman’s last known menstrual period. [1]

What Percentage of Abortions are D&Cs?

The Centers for Disease Control (CDC) collect abortion data each year. The results of their data collection are available online through 2014.[2] Abortion data since 2014 have not yet been published. All 50 states plus several large cities (like Washington D.C. and New York City) have the option to report their data to the CDC each year or not. For 2014, California, Maryland, and New Hampshire abortion numbers were not reported. In the CDC report, abortion methods are classified as surgical or medical (medication). Exactly how many surgical abortions were D&Cs was not reported.

What happens during a D&C?

Dilation

A D&C usually takes place in the abortion clinic, and rarely at a hospital. Before the abortion, the cervix must be dilated so that the abortion doctor can get the curette inside, and so that the fetal body parts can be taken out. Dilating the cervix happens in one of two ways. The first way is to use laminaria. Laminaria are long, slender rods of sterilized seaweed that swell by soaking up amniotic fluid. This causes the cervix to open or dilate.

The second way to dilate the cervix is with medications, most commonly one called Misoprostol or Cytotec. Cytotec is taken either orally as a pill or vaginally. This process of dilation may take a few hours or a few days.

Day Of Preparation

The woman will have to stop eating and drinking a certain amount of time before the abortion. The prep work also includes a pregnancy test, blood tests, physical exam, testing for sexually transmitted infections, and usually an ultrasound. The ultrasound confirms that the woman is pregnant and that she does not have an ectopic pregnancy. An ectopic pregnancy is when the fertilized egg implants outside of the uterus, also known as the womb. An ectopic pregnancy can be dangerous because often the fertilized egg implants inside a fallopian tube. As it grows, the fallopian tube can burst. This can cause life-threatening bleeding for the mother.

Procedure

After the ultrasound, the woman lies down on the exam table with her feet up in stirrups as for a pelvic exam. The abortion doctor uses tools to separate the walls of her vagina, to numb her cervix, and to hold the cervix in position for the abortion to happen. The woman will be given some type of anesthesia to keep her relaxed, or even asleep, throughout the abortion. The cervix will be cleaned with a solution to decrease the likelihood of infection. [3]

Sometimes, the abortion doctor suctions the fetal body parts out of the uterus before using the curette. Then, the doctor will scrape all the surfaces inside the uterus with the curette, a long, sharp, spoon-shaped tool. The fetal body parts and other contents of the uterus will be put in a tray or other container to be counted. If the abortion doctor leaves any body parts behind, they can cause life-threatening infection or bleeding for the mother.

Monitoring After the Abortion

The woman is monitored at the abortion clinic for up to several hours after the abortion, until the anesthesia wears off. Her heart rate, temperature, oxygen level, and blood pressure will be checked occasionally during this time. She usually has to take a few days off of work or regular activities due to fatigue, cramping, bleeding, and pain. She may be given a prescription for pain pills, or she may take over-the-counter medications like Ibuprofen. [4]

At what Point does the Fetus Die during the Abortion?

The fetus may die when the curette scrapes it, or when it is in the suction catheter. Or, it may die after it has been suctioned out and is in a jar or other medical waste container. Sometimes the abortion doctor needs to use forceps or some other medical instrument if a body part like a leg or arm gets stuck in the suction catheter.

What are the Side Effects or Complications of a D&C?

  • Injury to the cervix or uterus leading to preterm labor or miscarriage in future pregnancies[5]
  • Injury to the bladder or bowel or other organs caused by the curette breaking through the wall of the uterus[6]
  • Asherman syndrome[7]– bands of scar tissue form inside the uterus. This can stop a woman from having cycles if scar tissue blocks the exit of blood from the uterus. It can also lead to infertility, or to complications during future pregnancies like miscarriage or placenta previa

The World Health Organization notes that compared to suction abortion D&Cs are more painful to women, and have 2-3 times higher complication rates. [8]

How often do Complications occur?

Overall, the rate of serious complications from a D&C is directly related to how experienced the abortionist is. Risk of perforation, or poking a hole in the uterus, leading to heavy bleeding that requires a blood transfusion and hospitalization is higher for an abortion D&C than for a diagnostic D&C. This is because current or recent pregnancy makes the uterine tissue more likely to tear.

In a recent study, women who had had a D&C were 29% more likely to have a baby born pre-term, meaning before 37 weeks. Women who had had a D&C were 69% more likely to have a baby born very pre-term. Very pre-term means born before 32 weeks, when a baby is much more likely to have serious, lifelong brain, heart, lung, or other problems.

Researchers say that this is because in future pregnancies the cervix “remembers” being forced open for the abortion and starts to open earlier on its own. Another reason for pre-term birth could be that the cervix’s natural antibacterial properties are damaged, which makes the woman more likely to have an internal infection. Internal infections of the reproductive system are a pre-term birth risk factor.[9] [10] [11] Risk of preterm birth after D&C increases if a woman has more than one D&C. [12]

Abortion Methods: Dilation & Extraction (D&E Abortion)

What is a Dilation and Evacuation Abortion?

Dilation and Evacuation (D&E, also sometimes called Dilatation and Evacuation) is the most common type of surgical abortion during the second trimester in the United States. [1] A dilation and evacuation abortion implies two parts. The cervix must first be “prepared”, meaning dilated wide enough for the fetal parts to fit through. The second part is to dismember and remove or “evacuate” the fetus piece by piece.

History of D&E Abortion

Dilation and evacuation abortions were first performed in the United States in the 1970s. Dr. David Grimes, a late-term (including the second half of the second trimester and into the third trimester) abortion doctor published a research study on D&Es in 1977. [2] The biggest challenge in performing D&Es has always been getting the cervix to dilate, since its natural tendency at that point in the pregnancy is to remain closed. Japanese and European abortion doctors first developed a way to dilate the cervix gradually over several days with sterilized seaweed, called laminaria. Later on, synthetic dilators such as Dilapan and Lamicel allowed for even more dilation. Once greater dilation could be achieved, larger instruments could be used to reach through the cervix into the uterus to remove fetal body parts. Dr Warren Hern, another currently-practicing abortion doctor, developed instruments to rotate fetal body parts before removing them from the uterus. [3]

What percentage of Abortions are D&E Abortions?

The Centers for Disease Control (CDC) collect abortion data each year, and the results of their data collection are available online through the year 2014. [4] Abortion data since 2014 have not yet been published. States and several large cities like Washington D.C. and New York City have the option to report their data to the CDC each year or not. For 2014, California, Maryland, and New Hampshire abortion numbers were not reported. In the CDC report, abortion methods are classified as surgical or medical (medication). They report 652,639 abortions total, and almost 47,000 abortions in the second trimester.[5]

The second trimester typically refers to between 12 and 26 weeks after the last menstrual period. Some estimates say that up to 96% of abortions between 14 and 20 weeks along are D&Es. This statistic may not be accurate, though, because it comes from Centers for Disease Control and Prevention (CDC) data that also include other abortion methods. [6]

What happens during a D&E Abortion?

Cervical Preparation

“Cervical preparation” is recommended for all pregnancies over 12-14 weeks to reduce the risk of complications. [7] Dilating the cervix adequately is especially important for four groups of women. These include: teenagers, women with abnormal cervical anatomy, women who have had medical procedures done to their cervix before such as a colposcopy or cervical biopsy or LEEP (loop electrosurgical excision procedure), and women past 20 weeks gestation. [8] All of these groups have a higher likelihood of injury to the cervix and perforation or puncture of the uterus.

Different combinations of medicines and sometimes sterilized seaweed called laminaria or long, thin, synthetic rods called Dilapan-S or medicated sponges called Lamicel may be used to dilate or open the cervix so that the abortion tools and fetal body parts can fit through. [9]  The sponges and laminaria swell to absorb the amniotic fluid, forcing the cervix open. The medications chemically cause contractions and cervical softening and opening. One combination of medicines includes the same two medications, Misoprostol and Mifepristone, which are used for medical abortion in the first trimester.

Dilation of the cervix varies from one abortion doctor to another. Some of them start the process two days before the abortion, some the day before the abortion, and some just four hours before the abortion is performed. [10] Often, antibiotics will be given when the laminaria or other synthetic materials are placed to prevent infection. [11] More laminaria or Dilapan-S or Lamicel may be added to the cervix every few hours, or what’s currently in place may be removed and new materials may be placed.

Procedure Day

The day of the abortion, a brief history and physical are performed, blood samples are taken to check for sexually transmitted infections, an antibiotic pill will be given, and an ultrasound will be done. After the cervix has been dilated, the dismemberment and removal process only takes about 30 minutes. [12] The woman may be given pain medication such as Ibuprofen, anti-anxiety medication such as Valium, and some type of local anesthesia shot or shots to numb the cervix. Sometimes intravenous (IV) sedation medicine or general anesthesia are given since D&E is associated with significant pain, but general anesthesia also has higher complication rates than local anesthesia.

Dilation & Extraction

Once the pain and anxiety medications are given, the abortion doctor inserts a speculum, the same cold, metal gripping tool used during Pap smears in OB/GYN offices. The speculum may be weighted if the woman is past 16 weeks along. The speculum widens the vagina and makes the cervix more visible so that the abortion doctor can see what he or she is doing. A tenaculum is a gripping instrument with long handles and a clamp at the end that moves the cervix closer to the vaginal opening. Tenaculum may have sharp metal teeth to help hold the cervix in place. Ultrasound is often used to guide the abortion doctor. Dilators such as Dilapan-S or Lamicel or laminaria are removed. [13]

If the woman is less than 16 weeks along, the abortion doctor may be able to suction out the fetal parts like in a vacuum abortion. Once the fetus is older than 16 weeks, though, forceps are required. Forceps are grasping instruments used to grasp, crush, twist, and pull fetal body parts such as arms and legs or pieces of arms and leg out. The fetal head and spinal column often have to be crushed before they can be removed, especially the farther along the woman is. After the body parts are removed, the placenta is suctioned or scraped out, usually with the abortion doctor placing his hand on the woman’s stomach to help feel for it in the uterus.

After this, the abortion doctor or other staff have to reassemble all of the body parts to make sure that no fetal bone or other tissue remains.

At what point does the fetus die during the Abortion?

The World Health Organization suggests inducing fetal demise, making sure that the fetus is dead before the abortion, for women 20 weeks or more pregnant. This is because the fetus is easier to dismember if it is not moving. The two medications used together for first trimester medication abortion do not technically cause fetal death. In those abortions, the fetus typically dies during the violent contractions they cause. Similarly, and because the fetus is bigger, when one or both of those medicines are used to dilate the cervix before a second trimester abortion like a D&E, they are not expected to cause fetal death.

Fetal death is typically achieved through injection of a medication such as Potassium Chloride or Digoxin into the amniotic sac that holds the fetus. Potassium Chloride is very effective but requires a highly skilled doctor because accidentally injecting it into the mother’s bloodstream could kill her instead of the fetus. Potassium Chloride kills the fetus almost immediately, and the abortion doctor uses ultrasound to watch for the heart to stop beating. Digoxin, on the other hand, takes more time to stop the fetal heartbeat, but is safer for the woman, especially in cases of accidental injection into her bloodstream. It is less effective than Potassium Chloride in killing the fetus, and because it takes longer to act is often given one day before the abortion. This means an additional office visit for the woman seeking an abortion.

When fetal death is not induced before the D&E, the fetus dies when the abortion doctor crushes its skull with large forceps.

What are the Side Effects or Complications of a D&E Abortion?

Expected side effects include:

  • Pain, may be severe, especially if general anesthesia is not used[14]
  • Cramping
  • Bleeding

Serious complications include:

  • Cervical injury
  • Uterine perforation
  • Infection
  • Life-threatening hemorrhage (bleeding)
  • Uterine rupture
  • Incomplete abortion due to body parts or placenta or other tissue left inside the uterus
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding)
  • Anesthesia-complications such as respiratory depression[15]

Both cervical injury and uterine perforation can lead to life-threatening hemorrhage or bleeding. [16] A weakened or damaged cervix may lead to preterm labor or preterm premature rupture of membranes (bag of waters breaking) in future pregnancies. Either one of these conditions can end in miscarriage or in the baby being born before 37 weeks and having brain, lung, heart, and other problems. [17]

How often do Complications occur?

While only about 10–15% of all abortions are done in the second trimester, they are responsible for roughly two-thirds or 66% of all major complications. [18][19] Risk of death from second trimester abortion is over 20 times higher than from first trimester abortion. [20] Risk of death from abortion increases by 38% each week starting in the second trimester. [21] Generally, serious complications occur in about 1 in every 100 women who undergoes D&E abortion. [22] [23] [24]

Citations:

[3] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 158.

[6] Jatlaoui, T. C., A. Ewing, M. G. Mandel, K. B. Simmons, D. B. Suchdev, D. J. Jamieson, and K. Pazol. 2016. Abortion surveillance—United States, 2013. MMWR Surveillance Summaries 65(12):1–44.

[11] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 171.

[13] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 172.

[19] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 179

[22]  Grimes DA et al: Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: a pilot randomised controlled trial. BJOG 2004 Feb;111(2):148-53;

[23] Kelly T et al: Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomized controlled trial. BJOG 2010 Nov;117(12):1512-20

[24] Turok DK et al: Second trimester termination of pregnancy: a review by site and procedure type. Contraception 2008 Mar;77(3):155-61

Abortion Methods: D&X Abortion (Partial-Birth Abortion)

Dilation & Extraction (D&X), also known as Partial-Birth Abortion or Intact D&E or Intact D&X

What is a Dilation & Extraction Abortion?

From the law banning dilation & extraction abortions in 2003,  the legal definition of a D&X abortion is: “the person performing the abortion deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the [mother’s] body . . . , for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act, other than completion of delivery, that kills the fetus.” [1]

History of D&X Abortion

Independently of each other, Dr Martin Haskell, an abortion doctor from Ohio, and another abortion doctor in California started performing intact D&Xs on some women more than 16 weeks pregnant in the early 1990s. In 1992, Dr Martin Haskell presented a paper on intact D&Xs at a medical conference of the National Abortion Federation. Intact D&X abortions theoretically would have decreased complication rates because an intact delivery of the dead fetus would mean less likelihood of retained fetal body parts and tissue. Also, delivering the dead fetus aborted because of a medical anomaly (something wrong with the fetus potentially preventing it from living long or at all outside the womb) whole as opposed to in parts could potentially make for a better autopsy. Finally, delivering the dead baby whole could give his or her parents the opportunity to hold him/her and grieve his/her death. [2]

Court Cases

In 1997, Nebraska banned intact D&X abortions, which Supreme Court Justice Anthony Kennedy later called “a procedure many decent and civilized people find so abhorrent as to be among the most serious of crimes against human life.”[3]

In 2000, Stenberg vs Carhart, the Supreme Court struck down Nebraska’s ban on intact D&X abortions. Stenberg vs Carhart said that the ban was invalid because, among other reasons, it did not include an exception to allow for the life of the mother.  Partial birth abortion was later made illegal throughout the entire United States by a Supreme Court decision in 2003. In that ruling, the Supreme Court determined that an intact D&X abortion “is a gruesome and inhumane procedure that is never medically necessary and should be prohibited.” [4]

Two court cases, Carhart vs Ashcroft in 2003 and Planned Parenthood Federation of America vs Ashcroft in 2004, challenged this court ruling. In 2007, Gonzalez vs Carhart, the Supreme Court upheld the 2003 ban on intact D&X. [5] 

What percentage of Abortions are D&X Abortions?

Less than 0.5& of all abortions were estimated by Alan Guttmacher Institute (in 2006) to be D&X abortions. Now that this type of abortion is illegal, numbers are no longer tracked. However, video footage obtained during an undercover investigation by the Center for Medical Progress suggests that at least some Planned Parenthood affiliates may still be doing D&X abortions. The purpose of doing these D&X abortions would be to get intact fetal specimens for body part harvesting and sale. In the video, Dr Suzie Prabhakaran, an abortion doctor and Planned Parenthood medical director, described “checking a box” on abortion documentation to say that the doctor intended to use dismemberment, also known as the D&E (dilation & evacuation) method. If the fetus were actually aborted by D&X, the law would not technically be broken because the documented intent was to abort by dismemberment. [6]

Previously, another abortion doctor and Planned Parenthood executive named Dr Deborah Nucatola was recorded speaking about D&X abortions happening in Planned Parenthood clinics. She stated: “The Federal [Partial-Birth] Abortion Ban is a law, and laws are up to interpretation. So there are some people who interpret it as it’s intent. So if I say on Day 1 I do not intend to do this, what ultimately happens doesn’t matter.” [7]

What happens during a D&X Abortion?

Dilation

The “d” in D&X stands for “dilation,” and this starts one or more days before the abortion. The cervix typically has to be dilated more than with suction or D&C abortions because the baby is bigger. Oftentimes osmotic cervical dilators called laminaria start the process. Laminaria are long, thin rods of sterilized seaweed, and they soak up the amniotic fluid. This stretches and opens the cervix. Sometimes synthetic osmotic cervical dilators like Dilapan-S may be used instead. On the day of the abortion, Misoprostol, the early abortion pill, is often given to increase the dilation. If needed, surgical instruments may be used to manually stretch and open the cervix.

Extraction

After the cervix is adequately dilated, the abortion doctor pulls the baby feet first (this is called a breech presentation) until only its head remained inside. Then, the doctor punctures the head or back of the neck with sharp surgical scissors or a trochar, a hard, pointed metal tool. Then, they suction the fetus’ brain tissue out into a catheter which collapses the skull. The fetus is then delivered the rest of the way. [8]

Testimony

From testimony by a nurse for abortion provider Dr Martin Haskell, given during 2007 court case:

“Dr. Haskell went in with forceps and grabbed the baby’s legs and pulled them down into the birth canal. Then he delivered the baby’s body and the arms, everything but the head. The doctor kept the head right inside the uterus. . . . The baby’s little fingers were clasping and unclasping, and his little feet were kicking. Then the doctor stuck the scissors in the back of his head, and the baby’s arms jerked out, like a startle reaction, like a flinch, like a baby does when he thinks he is going to fall. The doctor opened up the scissors, stuck a high powered suction tube into the opening, and sucked the baby’s brains out. Now the baby went completely limp. . . . He cut the umbilical cord and delivered the placenta. He threw the baby in a pan, along with the placenta and the instruments he had just used. [9]

Variations on this procedure include: crushing the fetal skull with forceps, squeezing the fetal skull until the brain tissue oozes out and the skull collapses, or twisting the fetal head until it comes off of the rest of the body (decapitating it). [10]

At what point does the fetus die during the Abortion?

Typically, the fetus dies when the skull is pierced and the brain tissue is suctioned out.

What are the side effects of a D&X Abortion?

D&X abortion has the same general risks as any other surgical method of second trimester abortion. These include:

  • Non-white women undergoing surgical abortion are more than twice as likely as white women to die from the procedure
  • Obese women undergoing surgical abortions are more likely to have greater blood loss and increased procedure time
  • Retained fetal tissue, placenta, or amniotic sac can lead to life-threatening infection
  • Hematometra (abnormal collection of blood in the uterine cavity)
  • Bleeding severe enough to require a blood transfusion
  • Uterine atony (failure of the uterus to contract after abortion, causing uncontrolled bleeding)
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding disorder)
  • Infection (may require hospitalization)
  • Cervical injury
  • Uterine perforation (hole punctured in the uterine wall)
  • Asherman syndrome (scarring of the uterine lining or in the cervical canal potentially causing infertility, miscarriage, or preterm delivery in future pregnancies)
  • Deep vein thrombosis (potentially life-threatening blood clot, usually in legs)
  • Pulmonary embolism (life-threatening blood clot in one or both lungs)
  • Amniotic fluid embolism (amniotic fluid from fetal amniotic sac enters the mother’s blood stream)[11]

How often do Complications occur?

Between 1 and 2 of every 100 women who have a second trimester intact D&X abortion could expect to experience one or more of the serious complications listed above. [12]

Citations:

[2]Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009) 193.

[11] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 244-264.

[12] Ibid.

Abortion Methods: Saline Abortion

What is a Saline or Instillation Abortion?

An instillation abortion refers to any abortion where medication is injected or “instilled” into the uterus (womb), either inside or outside the amniotic sac that holds the fetus. Saline abortion is a specific type of instillation abortion, and the technical name is hypertonic saline abortion. Hypertonic saline is a highly concentrated salt solution. Other types of medications that can be instilled are urea, prostaglandins, and prostaglandin analogues. [1]

History of Instillation Abortion

Hypertonic Saline

Hypertonic saline was the first type of instillation abortion. Starting in the 1960s, saline abortions were typically done during the 2nd trimester because the uterus was easier to puncture at that gestational age. [2] Hyperosmolar urea, a highly concentrated kidney waste product, was also used for instillation abortions around the same time. [3]

Both these types of instillation abortion fell out of favor in the 1970s and 80s because of serious complications.  Several otherwise healthy women died after having them, and many abortions failed and ended up as live births. One study found that saline abortions were effective only 74% of the time. In other words, there were 26 failed abortions in every 100 women. [4]

Prostaglandins

As hypertonic saline and urea phased out, abortion doctors switched to instillation of prostaglandins. Prostaglandins are chemical messengers produced naturally by the body for different purposes. These purposes include: muscle contraction, blood clotting, inflammation, pain perception, the gastrointestinal or GI system, and other things. Prostaglandins also had many side effects, including strong GI symptoms like nausea, vomiting, and diarrhea. The latest version of instillation abortion, starting around the 1990s, is prostaglandin analogues. Prostaglandin analogues are slightly chemically modified versions of prostaglandins with fewer side effects.

Overall, prostaglandin analogues are routinely used nowadays, but they are not usually given by instillation. They are more likely to be given as pills, such as Misoprostol (see Medication Abortion article) because they have fewer side effects that way.

What Percentage of Abortions are Instillation Abortions?

Most Recent Data

A CDC report from 2007 reported that 0.5% of abortions that year were instillation abortions, which includes instillation of different substances: hypertonic saline, urea, prostaglandins, and prostaglandin analogues. The CDC website also reported that their abortion estimates were off by 35% from the Guttmacher Institute numbers. Guttmacher Institute numbers are considered the most accurate source for abortions statistics in the United States.[6] Theoretically, then, the actual number of abortions for the year would have been around 1.2 million, and about 12,000 of those would have been instillation abortions.

The most recent abortion numbers available are from 2014, but CDC numbers for that year do not break down types of abortion the way that the 2007 report did. They report 652,639 abortions total, and almost 47,000 abortions in the second trimester. If roughly 1% of those were instillation abortions, that would be around 6,000. [7] If the numbers are adjusted for Guttmacher estimates, there were just under 1 million abortions and around 10,000 of those were instillation abortions.

Instillation Abortions mostly done in the Second Trimester

The National Abortion Federation textbook, published in 2009, reports that in 1974 57% of abortions done after 13 weeks gestation were instillation abortions. By 2005, they estimated that number to be 0.4%. [5]

What happens during an Instillation Abortion?

Instillation as part of Induction Abortion

Instillation of medications is often done as part of an induction abortion. Usually, being “induced” means that a woman is given medications to make her go into labor and deliver the fetus at a specific time, often before the due date. This is done for a variety of reasons, such as if the mother’s blood pressure is getting too high, or the fetus is not growing properly in the womb anymore.

In an induction abortion, the plan is to go into labor but to deliver a dead baby. Instillation of medications causes fetal death and speeds up the labor process by softening the cervix and causing contractions. Instillation-before-induction abortions are done in hospitals.

Before the Abortion

Before the abortion, the woman has bloodwork and sexually transmitted infection screenings done. Vital signs like blood pressure and heart rate and temperature are recorded. An ultrasound will be done to confirm how far along she is. She may be given an antibiotic pill to prevent infection of the cervix, vagina, and uterus.

Often, her cervix will be dilated using laminaria, sticks of sterilized seaweed. This may be done up to 24 hours before the instillation.

Procedure

An injection is given into her abdomen (stomach area) to numb the skin around the needle. Next, the abortion doctor uses ultrasound to guide a long needle through the abdomen and into the uterus. Approximately one cup of amniotic fluid is removed to be sure that the needle is in the right place, and it is replaced with hypertonic saline or another medication. Inside the uterus, the medication is either injected into the amniotic sac that contains the fetus or into the space outside of the sac. [9] Afterwards,  labor inducing medications may be given through an IV. Typically, the woman will go into labor and deliver the dead fetus within about 24 hours.

At what point does the fetus die during the Abortion?

Instilled medications work in different ways. All ways are meant to kill the fetus before it is delivered. Hypertonic saline and urea cause severe dehydration, burning of the fetal skin and internal organs, and then death. The prostaglandins and prostaglandin analogues similarly break down the fetal tissue. This causes death, softens the cervix, and stimulates uterine contractions.

What are the Side Effects of an Instillation Abortion?

Hypertonic saline and urea instillation abortions can cause side effects:

  • Infection
  • Babies born alive, sometimes with deformities or other health problems

Melissa Ohden and Gianna Jessen are two well-known survivors of saline abortions during the 1970s. [10]  [11]

  • A life-threatening blood clotting disorder called disseminated intravascular coagulopathy (DIC)[12]
  • Life-threatening hemorrhage (bleeding) [13]
  • Seizures
  • Death

For example, 3 otherwise healthy women died in 1966 due to seizures after saline abortions. Hypertonic saline is a highly concentrated sodium (salt) solution. If it leaks out of the uterus and into the bloodstream, it causes major problems for the woman. Besides leaking out through a hole (or perforation) punctured in the uterus, the medication can also be accidentally instilled into the bloodstream instead of the uterus. In the bloodstream, the salt solution travels throughout the body. Too much sodium in the brain causes severe swelling and bleeding. Severe swelling and bleeding can cause seizures and ultimately death. [14] Hypertonic saline accidentally given into the bloodstream can also cause a life-threatening blood clotting disorder called disseminated intravascular coagulopathy (DIC).

Prostaglandins and prostaglandin analogues can cause:

  • Severe abdominal pain
  • Nausea
  • Vomiting
  • Diarrhea
  • Fever
  • Shivering [15]
  • Vaginal bleeding, sometimes requiring blood transfusion [16]
  • Cervical fistulae (abnormal opening between the cervix and the vagina or bladder causing leakage of urine) [17]
  • Uterine rupture (can be life-threatening), typically in women who had previously had a Cesarean section (C-section) [18]

Induction abortions are specifically associated with retained placenta, which puts the woman at risk for life-threatening infection.

How often do Complications occur?

Life threatening blood clotting and bleeding after prostaglandin analogue abortion occurs in approximately 1 in every 100 women. [19]  Research has shown that induction abortions can be complicated by retained placenta up to 30% of the time. [20]

While only about 10–15% of all abortions are done in the second trimester, they are responsible for roughly two-thirds or 66% of all major complications. [21][22] Risk of death from second trimester abortion is over 20 times higher than from first trimester abortion. [23] Risk of death from abortion increases by 38% each week starting in the second trimester. [24]

Citations:

[1] Many research studies and resources cited in this document are from the 1970s and 1980s because more recent research on instillation abortions has not been done.

[3] While most sources are from the 1970s and 1980s, one case report from the United Kingdom of a urea instillation abortion was published in 2009.

[5]  Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 158.

[17] Berger, G., Bygdeman, M., and Keith, L.G. Prostaglandins and their Inhibitors in Clinical Obstetrics and Gynaecology. (Springer Netherlands, 1986), 297.

[20] Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002; 187: 393– 397.

[22] Cassing Hammond MD, and Stephen Chasen MD, “Dilation and Evacuation,” Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009), 179.

Citations:

Abortion Methods: Medication Abortion, Abortion Pill, RU-486

We will review the different methods of abortion currently used in the United States. Here we will give you a detailed overview of medical abortions.

What is a Medication Abortion?

They often go by various names:

    • Medication Abortion
    • Medical Abortion
    • Abortion Pill
    • RU-486

History of Medication Abortion

In 2000, the United States Food and Drug Administration (FDA) approved two abortion pills. The two medicines are mifepristone and misoprostol. [1]

In 2016, the FDA approved a new label for the medicines. This change allowed for lower dosages, increased gestational age limit, and fewer follow up visits.

How Common is Abortion by Medication?

Medication abortion is increasingly popular. It accounted for 6% of nonhospital abortions in 2001, and 31% by 2014 (the most recent year for which data are available according to the Guttmacher Institute, the former research arm of Planned Parenthood). [2]

This is for several reasons.

Medication abortion is cheaper for abortion providers. A patient is typically charged the same amount for either a medication abortion or a surgical abortion. The medication abortion, though, takes less manpower, clinic time, and does not involve anesthesia. The woman is responsible for giving herself Ibuprofen and relieving her own pain outside the clinic.

Also, abortion advocates want nurse practitioners and physician assistants to offer medication abortion. They say that simply performing a physical exam and giving a pill does not require a doctor. Pro-life advocates point out that abortion is not routine healthcare, and that it’s potentially very serious consequences deserve the oversight of an actual physician.

Prescribed medicines usually come from a pharmacy, and the patient can ask the pharmacist if they have questions. The abortion pill is only available at an abortion clinic. The abortion doctor signs very detailed paperwork about the abortion medicines and returns it to the manufacturer.

What happens during a Medication Abortion?

First, an ultrasound is done to confirm that the pregnancy is intrauterine (inside the uterus) and not ectopic (growing outside the uterus). A nurse or other staff member takes the woman’s vital signs like heart rate and blood pressure. The abortion doctor also listens to the woman’s heart and lungs with a stethoscope and does a pelvic exam, except in webcam abortions (see below). Sometimes, the woman receives antibiotics to prevent infection.

Mifepristone or Mifeprex or RU-486, is the first medicine. It is given to the woman at the abortion clinic. Misoprostol is the second medicine. The woman takes Misoprostol at home. 

The abortion usually takes  24-48 hours after the second medicine, Misoprostol, is taken. The woman signs a Patient Agreement Form that she will come back for a follow up appointment in 14 days. This is to be sure that the abortion worked. In 2-7% of cases, this type of abortion does not work. If that happens and the woman is still pregnant, she is then encouraged to have a surgical abortion such as a dilation and curettage (D&C). If she chooses to carry the baby to term after a failed medication abortion, the baby might have birth defects.  

About the Drugs used in Medical Abortion

Mifepristone works by blocking progesterone. Progesterone is the hormone that sustains pregnancy. Without progesterone, the lining of the uterus breaks down and sheds like in a menstrual period. This cuts off nutrients and support to the fetus. [3]

Misoprostol was first developed to prevent stomach ulcers in people who take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or advil. [4]  Another way it works is by releasing prostaglandins in the body. This effect is the reason Misoprostol is part of medication abortions. Prostaglandins cause the uterus to have contractions and expel the dead fetus. This happens while at home and the fetus is usually expelled into the toilet. These strong uterine contractions are said to feel like the pain from very strong period cramps. According to Planned Parenthood’s own website, fetal tissue may be visible along with “lots of bleeding.” 

In very rare cases, when a woman is allergic to Mifepristone, a different medication called Methotrexate may be used by itself without the Misoprostol. Methotrexate is typically a chemotherapy medication or a rheumatoid arthritis treatment. In medication abortion, it kills the embryo by stopping the reproduction of fast-growing fetal cells.

At what point does the Fetus die?

Typically, the fetus dies when its nutrients are cut off because of the first abortion medicine, Mifepristone.

What Percentage of Abortions are Medication Abortions?

Medication abortion is increasingly popular. It accounted for 6% of nonhospital abortions in 2001, and 31% by 2014 (the most recent year for which data are available according to the Guttmacher Institute, the former research arm of Planned Parenthood). [5]

This is for several reasons.

Medication abortion is cheaper for abortion providers. A patient is typically charged the same amount for either a medication abortion or a surgical abortion,  but the medication kind takes less manpower, clinic time, and does not involve anesthesia. The woman is responsible for giving herself ibuprofen and relieving her own pain outside the clinic.

Also, abortion advocates want nurse practitioners and physician assistants to offer medication abortion. They say that simply performing a physical exam and giving a pill does not require a doctor. Pro-life advocates point out that abortion is not routine healthcare, and that it’s potentially very serious consequences deserve the oversight of an actual physician. Prescribed medicines usually come from a pharmacy, and the patient can ask the pharmacist if they have questions. The abortion pill is only available at an abortion clinic. The abortion doctor signs very detailed paperwork about the abortion medicines and returns it to the manufacturer.

Side Effects of the Abortion Pills [6]

Abortion is never safe for the developing embryo or fetus. A medication abortion is also not safe for women themselves who meet any of the following criteria:

    • Pregnancy greater than 10 weeks along
    • An ectopic pregnancy, also known as pregnancy outside the uterus
    • Have an intrauterine device (IUD) currently in place
    • History of adrenal gland problems
    • Take blood thinners
    • Have a blood clotting disorder or other bleeding problem
    • Have porphyria
    • Take steroids
  • Have an allergy to misoprostol, mifepristone, or other prostaglandins

Common side effects up to 24 hours after taking the medicines can include:

    • Nausea/vomiting
    • Weakness
    • Fever/chills
    • Headache
    • Diarrhea
  • Dizziness

Rare but serious side effects include:

    • Life-threatening bleeding requiring hospitalization and possibly a blood transfusion
  • Life-threatening infection

Bleeding is not listed as a side effect because it is expected. This does not mean that the amount of bleeding will necessarily be safe. Serious or life-threatening bleeding is more likely with medication abortion because of the way the medicines work. Since every woman’s body reacts differently to medications, some women’s bodies may not automatically stop bleeding and contracting just because the fetus has already been expelled. This can progress to life-threatening bleeding depending on how much the woman bleeds and how long she bleeds for.

Additionally, there is a risk of infection. This risk is highest for women who experience “incomplete abortion.” This is when the fetus is dead and expelled but the body retains some of the membranes or placenta that were supporting it. [7]

How often do Complications occur?

In a 2014 research study in California, there were four times as many complications from medication abortions as surgical abortions in the first trimester. About 5.2% of women had to go to the emergency room for a medication abortion complication. [8] In another research study in Finland, there were four times as many complications from medication abortions at or before 7 weeks gestational age compared to surgical abortions. 20% of women, or 1 in every 5 women, who had medication abortions in the study experienced a complication. [9]

Deaths from the Abortion Pill

After the original FDA protocol was released in 2000, eight young women who took Misoprostol vaginally died of a bloodstream infection caused by clostridium sordelli bacteria. The FDA protocol did not mention vaginal use, but this “off-label” use was common at the time.  The FDA said those deaths were “infection-related” rather than “abortion-related. ” Nowadays, Misoprostol is no longer used vaginally. It is placed inside the cheek until it dissolves.

In total, 22 women who took RU-486 have died since 2000. 2 of those women died from ruptured ectopic pregnancies, even though the FDA insert says that no woman with an ectopic pregnancy should take RU-486. [10]

In 2016, the FDA accepted off-label dosages that were being widely used by abortion doctors, instead of the dosages from the 2000 protocol. When this protocol change was made, no safety research studies were cited.

What are Webcam or Telemedicine Abortions?

Telemedicine or “webcam” abortions are becoming more popular. After an ultrasound and a review of the woman’s medical history, she takes the first medicine in clinic. A physician watches remotely on a webcam. Abortion advocates say that webcam abortions give rural woman more access. Pro-life advocates point out that women miss out on an actual physical examination. Also, living in rural areas could mean less access to a hospital when complications occur. Iowa was the first state to pilot webcam abortions, and Sue Thayer managed a Planned Parenthood clinic there. She was fired for refusing to participate.

As this article was being written, California’s legislature is considering HB320, which would mandate that health centers at state-run colleges and universities dispense abortion medicines.

What if I Change my Mind?

For women who have only taken Mifepristone and change their minds, stopping the abortion may be possible. A large dose of oral progesterone may be able to reverse Mifepristone’s effects. In a research study, the abortion was effectively stopped in 68% of patients who took the progesterone. More information is available here: https://abortionpillreversal.com/

What does Baby Look Like at 10 weeks?

At 10 weeks, the brain, heart, lungs, liver, and kidneys are all formed. Baby’s heart has been beating since about 3 weeks. Baby’s fingernails and hair are starting to grow.

Abortion Methods: Intracardiac Abortion

We will review the different methods of abortion currently used in the United States. Here we will give you a detailed overview of  intracardiac abortions.

History of Intracardiac Abortion

The first successful intracardiac abortion was in 1978.[5] A woman pregnant with twins chose to abort a fetus with a lethal disease with the hope of saving its twin. Since then, abortionists have used injectable medications particularly before second or third trimester dilation & evacuation (D&E) abortions, to make sure that the fetus is dead before it is delivered.

Reasons for Intracardiac Abortion

Reasons for these late term abortions include aborting fetuses who have a disability that won’t allow them to live outside of the womb, or who may have health issues for the rest of their life after birth like Down Syndrome. Injected medication abortions are also sometimes done after in vitro fertilization.

Selective Reduction

Abortion of one or more fetuses after in vitro fertilization is called “selective reduction.” Abortion after in vitro fertilization might not seem to make sense, since the couple was obviously trying to get pregnant.  However, as part of in vitro fertilization, typically multiple embryos are implanted in the woman’s uterus. That way, there’s a higher likelihood of having at least one live birth.

But, sometimes multiple embryos survive the transfer process from the lab to the womb. The risk of health problems if these embryos live until birth is high. There are higher rates of preterm (early) delivery, low birth weight, brain problems, development problems, and many other issues if multiple babies are born at once rather than if just one baby is born at a time.

“Selective reduction”, then, is the process of aborting one or more of these fetuses so that the one (or two) fetus(es) that makes it to birth has (have) a higher chance of being relatively healthy. [6]

End Goal

Whatever the reason that the woman may be aborting, these medications are injected to ensure that the fetus is not alive when it is born. Some women who are aborting fetuses with health problems believe that abortion is the “merciful” thing to do. They want to be sure that the fetus isn’t alive when it is born because then they would feel conflicted about trying to resuscitate it or watching it die.

Connection to Partial Birth Abortion 

Also, the Partial Birth Abortion Act of 2003 in the United States states that killing a living fetus when it has been partially delivered from the woman’s body is illegal. [7] Some abortion doctors make sure that the fetus is dead before delivery so that they don’t get in trouble for breaking this law.

What are Intracardiac Abortions?

An intracardiac abortion happens when a medication being injected through the pregnant woman’s abdomen (stomach area) into the fetal heart. The medicine stops the fetus’ heart from beating.

Potassium Chloride

This is often done with a medicine called Potassium Chloride. Outside of its use in abortions, Potassium Chloride is also one of several medicines given for execution of prisoners by the death penalty.

Digoxin

Medications to stop the fetus’ heartbeat are also sometimes injected into the amniotic fluid around the fetus, or into a random fetal body part. The most common of these medicines is called Digoxin.[1]

Outside of its use in abortions, Digoxin was originally developed for adults  to make the heart beat stronger and with a regular rhythm, or to treat an irregular heart rhythm called atrial fibrillation. Digoxin injected into the fetus is given in a lethal dose that slows the heart beat gradually until it stops.

Research

In research studies, injected Digoxin failed to stop the fetal heartbeat in 6.6% to 13% of abortions. [2][3] In research studies, Potassium Chloride failed less than 1% of the time. [4]

What Percentage of Abortions are Intracardiac Abortions?

The Centers for Disease Control and Prevention (CDC) collect abortion data each year, and the results of their data collection are available online through the year 2014.[8] Abortion data since 2014 have not yet been published. States and several large cities like Washington D.C. and New York City have the option to report their data to the CDC each year or not. For 2014, California, Maryland, and New Hampshire abortion numbers were not reported.

In the CDC report, abortion methods are classified as surgical or medical (medication). Exact numbers on how many of these surgical abortions were intracardiac abortions are not available because most of the states that report their data to the CDC did not provide this information.

The studies used in this article included from fewer than 10 up to nearly 5,000 women. Studies of digoxin included 8 women, 126 women, and 4,906 women. [9] [10] [11] Studies of Potassium Chloride included 192 women and 239 women. [12] In one study from Britain in 2004, where abortions by type are tracked better than in the United States, about 1% of abortions were intracardiac or injectable. [13]

What Happens During an Intracardiac Abortion?

On the day of the procedure, the woman first has a blood sample drawn to check her blood type, and vital signs like heart rate and blood pressure taken. She is positioned on the clinic or hospital bed as if she were having a regular pregnancy ultrasound. A numbing shot is given through a small needle into her belly. Then a long, large needle with the medicine in it is put in her belly. An ultrasound is used to determine where the fetal heart is, and when the needle is in the fetal heart.

The medicine is then injected, and the abortion doctor watches on the ultrasound screen until the heart stops. An ultrasound is often done again 30 minutes after the fetal heartbeat has stopped, to make sure that it is still stopped.

After the fetal death, the woman may be induced or may wait up to several weeks to go into labor on her own. [14] Sometimes, she goes into labor and delivers the stillborn baby before she can get back to the hospital. If she does deliver at the hospital, sometimes it is on a bed as with a planned live birth, and other times it is into a toilet.

A visual overview is here.

At What Point Does the Baby Die During the Abortion?

Typically, the baby dies within several minutes after a Potassium Chloride injection because the medication stops its heartbeat immediately. The abortionist watches the ultrasound until it shows that the heart has stopped. With Digoxin, fetal death can take hours.

An ultrasound may be done periodically to check when the heart stops beating. Around 30 minutes after electrical activity stops, another ultrasound is done to confirm that the heart has not started beating again. If the heart has restarted, a repeat dose of medication may be given. [15]

What are the Side Effects of an Intracardiac Abortion?

Side effects after a Potassium Chloride injection abortion are different from a Digoxin injection abortion. Digoxin injections are not recommended as standard practice before a dilation and evacuation abortion because they don’t decrease how long the abortion takes. Side effects include vomiting, women going into labor on their own at home or other places before the scheduled dilation and evacuation, and infections inside the uterus. Digoxin cannot be given to any woman with a history of Wolff-Parkinson-White syndrome. [16]

In one Potassium Chloride study, a woman suffered cardiac arrest (her heart stopped) and was successfully brought back to life. In another research study, a woman developed a life-threatening infection after the medicine was accidentally injected into her bloodstream instead of into the fetus’ heart. [17]

How Often Do Complications Occur?

Complications other than vomiting occurred less than 1% of the time in women who received Digoxin injections. Vomiting occurred in around 15% of women. Complications occurred less than 1% of the time in women who received Potassium Chloride injections, but when they did occur they were very severe (see above).

Sometimes intracardiac injections are given before a woman is induced to go into labor. Research shows that induction abortions can be complicated by retained placenta up to 30% of the time. Retained placenta puts the woman at significant risk for life-threatening infection. [18]

Citations:

[16] [16] Cassing Hammond MD, and Stephen Chasen MD, Management of Unintended and Abnormal Pregnancy. Ed. Paul, Lichtenberg, Borgatta, Grimes, Stubblefield and Creinin. (Wiley-Blackwell, 2009).

[18] Autry AM, Hayes EC, Jacobson GF, Kirby RS. A comparison of medical induction and dilation and evacuation for second-trimester abortion. Am J Obstet Gynecol 2002; 187: 393– 397.

Is Abortion ever Medically Necessary?

Most abortions laws in the United States of America have exceptions for cases of rape, incest, and “life of the mother.” Whatever the restrictions on abortion are in the particular law, cases of rape, incest, or endangerment of the mother’s life are still legal.

Let’s examine the legal meaning of “medically necessary” abortions and whether they are the same thing as abortions for the life or health of the mother. We’ll also look at what types of health conditions fall under “medical necessity”, how often they are performed, and who pays for them. We’ll also study the pro-life response to “medically necessary” abortions. “Medically necessary” abortions are typically performed starting in the middle or late second trimester and may be performed throughout the third trimester. We’ll conclude by examining possible complications of these late-term abortions.

What is the Legal Definition of “Medically Necessary”?

Pro choice advocates claim that abortion must be legal because some abortions are not elective, and are in fact “medically necessary.” The term “medically necessary” originated in the 1940s, “to ensure that hospitals and physicians were paid for the services they performed.” [1] It was a vague catchall phrase used by insurance companies that mostly relied on physician judgment about what services were necessary for a patient’s care. Abortion rights advocates ever since Roe v Wade and Doe v Bolton in 1973 have argued that “medical necessity” is an objective standard based on medical judgment. But in reality, “medical necessity” is more nuanced because “doctors often differ in their estimation of comparative health risks and appropriate treatment.” [2]

Is “Medically Necessary” the same as “Life of the Mother”? What about “Health of the Mother”?

“Health of the Mother” and “Life of the Mother”

As we’ll see by the legal definition of maternal “health” below, “medically necessary” abortions can technically include abortions for the life of the mother or the health of the mother.

Abortions to “save the (physical) life of the mother” are recommended for a variety of maternal reasons, including the mother having preexisting heart disease or uncontrolled diabetes or cancer. Sometimes, the mother develops pregnancy complications like preeclampsia or eclampsia (toxemia of pregnancy) or chorioamnionitis. [3]

Abortions to “save the life of the mother” also may be recommended when something goes wrong with the fetus itself, as in ectopic or molar pregnancies.  Abortions for the “health of the mother” generally refer to medical conditions which cause the mother illness and varying degree of physical discomfort. One example is gestational diabetes (diabetes that develops during pregnancy and goes away when the fetus is delivered). Another example is hyperemesis gravidarum (severe nausea and vomiting during pregnancy). “Health of the mother” conditions do not endanger the mother’s life.

Doe v Bolton

“Mary Doe” in Doe v Bolton was a Georgia woman who sought an abortion at 9 weeks pregnant in 1968. “Bolton” in Doe v Bolton was Arthur Bolton, Attorney General of Georgia. Mary Doe wanted an abortion because she was financially unable to provide for another child. She also did not have custody of any of her three other children. She had been a patient of a mental hospital. Finally, she had recently been left by her husband. At that time, Georgia law allowed for an abortion only in the following cases: 1) endangerment of or serious and permanent injury to the woman’s life 2) pregnancy because of rape 3) baby “very likely” to be born with a grave mental or physical defect. [4]

The Doe v Bolton case started in a district court and went all the way to the Supreme Court. The case was decided on the same day in 1973 as Roe v Wade. Doe v Bolton set a legal precedent, or legal definition of a term that is used in other court cases on similar topics in the future. That legal precedent says that the “health” of the mother includes her physical, emotional, psychological, and familial health, and her age. This Supreme Court ruling struck down many state restrictions on abortion. [5] So, any pregnancy that could impact the mother’s physical, emotional, psychological or family health could be grounds for a “medically necessary” abortion. Likewise, presumably a woman who is older than 35 years or younger than, say, 18, could also have grounds for a “medically necessary” abortion.

How often are Abortions performed for “Medical Necessity”?

The Alan Guttmacher Institute has published several studies on reasons that women have abortions. One of these was published in 1987, and another was from 2004. In both studies, “mother has health problems” was cited in 2.8-4% of cases. “Mother has health problems” is another term for “medically necessary” cases and includes both life-threatening and non-life-threatening cases. So, the total of abortions done for the life of the mother is, at the most, less than 4% of all abortions. The most recent abortion statistics are from 2014, and there were 652,639 abortions that year. At the most, then, somewhere between 13,053 and 26,106 abortions were for “medically necessary” reasons, and a portion of these would have been for “life of the mother” cases. [6]

Are Tax Dollars used for “Medically Necessary” Abortions?

Medicare and Medicaid

Tax dollars pay for both Medicare and Medicaid. [7] Medicare is a federal health insurance program available to all American citizens over age 65. Tax payer money goes directly to Medicare at the federal level. Every American citizen who gets a paycheck pays a small percentage of their earnings directly into Medicare. Since Medicare covers Americans over age 65, there is no argument about it covering abortions since all women participants are past child-bearing age.

Medicaid is a health insurance program for poor Americans. Medicaid has both federal and state branches. Each state has its own office and its own rules for eligibility. Some funds from incomes taxes go to Medicaid at the state level. Other federal funds support Medicaid at the national level. [8]

Hyde Amendment

The Hyde Amendment states that federal Medicaid funds cannot be used for abortions except in cases of rape, incest, or the mother’s life being endangered. [9] The Hyde Amendment was originally passed in 1976. Every president since then has either repealed or reinstated the Hyde Amendment depending on his political affiliation.

In 17 states, only state Medicaid money is used to pay for medically necessary abortions. No federal funds are used in these states. In the other 33 states of the 50 states total, federal Medicaid funds are used for some “medically necessary” abortions. [10]

A research study of 25 abortion providers in 6 different states found that in many cases Medicaid did not reimburse them for abortions that qualified under the Hyde Amendment. Many providers reported that going through so much paperwork only to be turned down was a waste of their time. In the few cases where they did actually get reimbursed, the amount of money was so small that it was not worth their time to keep applying. [11]

What is the Pro-life Response to “Medically Necessary” Abortions?       

Moral Principle of Double Effect

Pro-lifers respond that the goal of medical interventions should always be to save life. In select rare cases, the fetus may die as a result of interventions to save the mother’s life. However, the goal is never to purposefully end the life of the fetus. [12] This concept is called the moral principle of double effect, a good action is done that has a foreseen bad side-effect. [13] So, in the case of a woman with uterine cancer, she might have to have her uterus removed to get rid of the cancer. The fetus would unfortunately die as a result, but the woman was helped as a result of the uterus being removed and not because of the fetus’ death.

Moral Principle of Double Effect and Flight 93

Let’s take another example of the moral principle of double effect. Recall the passengers of Flight 93 on September 11, 2001? When they learned that the plane had been hijacked, they made a decision to resist and to prevent the plane from hitting the hijackers’ target. Their goal was to save lives, even though they knew that in the process they would lose their own. So, the goal was to save lives, even though they foresaw that the bad side effect would be their own deaths. Each passenger was granted the Congressional Medal of Honor for this bravery. Pro-lifers abide by this same principle when a mother’s life is in danger.

The Dublin Declaration

The Dublin Declaration on Maternal Healthcare was written in 2012 and signed by over 1,000 Irish obstetricians and other healthcare professionals. It states that:” direct abortion – the purposeful destruction of the unborn child – is not medically necessary to save the life of a woman. We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child. We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.” [14]

What about Abortion for Maternal Health Conditions?

Some medical problems may be exacerbated by pregnancy. These include preexisting heart disease and diabetes and a known or new diagnosis of cancer. Typically, close monitoring and treatment of heart disease or diabetes by a maternal-fetal medicine specialist, also known as a high-risk pregnancy doctor, can prevent threats to the mother’s life. In rare cases where the mother’s life is in danger the longer that the pregnancy continues, the fetus can be delivered early either through induction of labor or a cesarean section.

Generally, a fetus is viable, or can live outside the womb with medical assistance, starting around 24 weeks (less than 6 months pregnant). If a woman has cancer and needs treatment, the treatment could either be started promptly and potential birth defects be managed after delivery, or treatment could be delayed until an early delivery is achieved. Either of these options ensures effective treatment of the woman’s health conditions, and respects the life of the fetus to the fullest extent possible.

Occasionally, a mother decides to forego medical treatment altogether, to give her baby the best chance at a healthy life. While this is not necessary from an ethical standpoint, it is consistent with mothers throughout history who have given their lives to save their children. Mothers have run into burning buildings to rescue children, carried them on their backs through flooded waters, and jumped into dangerous waters to save a drowning child. [15]

What about Abortion for Preeclampsia or Eclampsia?

Preeclampsia, also known as toxemia of pregnancy, develops after 20 weeks of pregnancy and involves high blood pressure and oftentimes kidney, liver, heart, lung, or eye damage. Preeclampsia plus seizures is considered eclampsia. Uncontrolled high blood pressure can lead to seizures, stroke, and even death of the mother. Liver, kidney, heart, or lung failure can also be life-threatening.

Once symptoms start, they do not generally go away until the pregnancy ends. Typically, goals of treatment include outpatient medications to control blood pressure, and frequent doctor’s office monitoring of fetal wellbeing. If symptoms are severe enough, the mother has to be hospitalized until delivery. She is often on intravenous (IV) medication to prevent seizures.

Once a fetus reaches the age of viability, labor can be induced or a Cesarean section performed. If the mother progresses to eclampsia before 24 weeks, the fetus must be delivered regardless. This would not be considered a direct abortion because the goal would be to end the pregnancy by delivery, not to kill the fetus. The preterm fetus would not be expected to live outside the womb, but its death would not be directly caused. [16]

Preeclampsia occurs in between 5 and 8 pregnancies out of 100, but progression to life-threatening eclampsia is rare with proper treatment. [17]

What about Savita Halappanavar?

In 2012, a woman named Savita Halappanavar who was living in Ireland went into the hospital at 17 weeks pregnant with symptoms of a miscarriage. Her situation was unusual from the beginning, as only 1-2% of all miscarriages occur during the second trimester.

Unfortunately, the miscarriage was related to an uterine infection called chorioamnionitis, which was not diagnosed and treated appropriately and in a reasonable timeframe. Chorioamnionitis is typically treated by intravenous (IV) antibiotics, and spontaneous miscarriage of the fetus often occurs. If spontaneous miscarriage does not occur, the fetus may have to be delivered regardless of gestational age because infection in the fetus can progress to life-threatening systemic infection via the mother’s bloodstream. This would not be considered a direct abortion because the intent was to deliver the pregnancy, though the fetus was not expected to survive due to prematurity.

By the time that the spontaneous miscarriage completed, Savita’s untreated infection had progressed to her entire bloodstream and caused organ damage, a condition known as sepsis. Her sepsis worsened to severe sepsis and then septic shock. Her heart stopped, causing her death, seven days after she entered the hospital.

Abortion advocates called for a repeal of Ireland’s abortion laws. They argue that if Savita had received an abortion then she would not have developed sepsis. Unfortunately, the facts lead to a different conclusion in Savita’s case. The investigation into her death found that the real problems were that she was not monitored closely enough, that the fetus’ infection was not treated appropriately, and that her own possibility of infection was not anticipated correctly.  By the time her treatment team realized just how sick she was and responded, it was too late. [18]

What about Abortion for Ectopic Pregnancies?

An ectopic pregnancy occurs when the embryo implants somewhere other than the woman’s uterus, oftentimes in a Fallopian tube. Because the Fallopian tube is small, the pressure of the growing embryo on the Fallopian tube can cause it to rupture. Fallopian tube rupture can lead to life-threatening complications.  Ectopic pregnancy affects about 1 in 50 to 1 in 100 pregnancies. [19]

Ectopic pregnancies can be treated in three ways. Two of these ways arguably constitute a direct abortion. Methotrexate is considered a direct abortion because it stops production of the trophoblast. The trophoblast is produced by the embryo and normally develops into the placenta. [20] Salpinogotomy is also considered a direct abortion. The Fallopian tube is sliced open and the embryo is scooped out and dies. The woman’s Fallopian tube may still function correctly in the future.

Salpingectomy is not considered direct abortion because the whole diseased section of the Fallopian tube is removed. The death of the embryo inside is an undesired but expected side effect. Because a section of the Fallopian tube is removed, that tube will not be functional in the future. Having only one functional Fallopian tube reduces the woman’s fertility. [21]

What about Abortion for Hydatidiform Mole or Molar Pregnancies?

A hydatidiform mole, also known as a molar pregnancy, may be a partial (or incomplete) molar pregnancy or a complete molar pregnancy. Something goes wrong during fertilization of the egg by the sperm. The placenta develops abnormally and the fetus develops only partially (partial molar pregnancy) or not at all (complete molar pregnancy). In rare cases, the placental mass that develops from the molar pregnancy may become cancerous. This cancer can be life threatening, but is generally treated successfully with chemotherapy. [22]

Complete molar pregnancies occur in about 1 in 1,000 pregnancies. [23] Incomplete or partial molar pregnancies occur less frequently. If the embryo does not develop, a dilation & curettage procedure is recommended to clean out the uterus. This would not be considered a direct abortion because there is no life there. If an embryo does partially develop, the woman will typically miscarry.

What kind of Complications can occur during “Medically Necessary” Abortions in the 2nd or 3rd Trimester?

Late term abortions, or abortions performed in the second half of the second trimester or anytime during the third trimester, require several days to dilate the cervix. Risk of death from abortion increases by 38% each week starting in the second trimester. [24]  Serious, documented risks for late-term abortions include:

  • Cervical injury
  • Uterine perforation
  • Infection (may become life-threatening)
  • Life-threatening hemorrhage (bleeding)
  • Uterine rupture
  • Incomplete abortion due to body parts or placenta or other tissue left inside the uterus
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding)
  • Anesthesia-complications such as respiratory depression[25]

So, is abortion ever medically necessary?

We see from the examples above that direct abortion is never medically necessary to save the life of the mother. In rare cases where the mother’s life is in danger if the pregnancy continues, the baby can be delivered via induction or cesarean section. If the baby has not yet reached the age of viability, the mother and her medical team may anticipate the baby’s death after delivery as an unintended consequence. In these unfortunate cases, perinatal hospice programs can help facilitate and guide the woman and her family through the bonding and grieving process. This approach respects the lives of both the mother and her child. [26]