The third and final presidential debate focused very quickly on abortion. Clinton defended choice, and Trump ― not one to be bothered with facts ― countered with this doozy of a line:
I think it’s terrible if you go with what Hillary is saying... in the ninth month you can take the baby and rip the baby out of the womb of the mother just prior to the birth of the baby. Now, you can say that that’s okay, and Hillary can say that that’s okay, but it’s not okay with me. Because based on what she’s saying and based on where she’s going and where she’s been, you can take the baby and rip the baby out of the womb in the ninth month, on the final day. And that’s not acceptable.
First of all, we don’t “rip” anything in OB/GYN. In surgery, we use sharp dissection and blunt dissection, but we don’t rip. Some women do tear during a vaginal delivery, but that’s not a doctor ripping the baby out. Even with a forceps delivery, I wouldn’t call it ripping. We also don’t rip tissues during c-sections.
Perhaps we can forgive Donald Trump for not knowing this as it is hard to believe that a man who bragged that he doesn’t change diapers and said he wouldn’t have had a baby if his wife had wanted him to actually physically participate in its care would have attended the birth of his own children. It’s certainly not for the faint of heart as there is, after all, lots of blood coming out the “wherever.”
Trump’s statement, as incorrect as it may be, supports the fallacy of the due-date abortion. It is a common anti-choice narrative that women come in at 39 weeks and have some kind of abortion for fun or out of boredom and that we doctors are only to happy to comply. I’m sure some people think there are Groupons. The more graphic the description of the procedure the better, as it helps to distract from the facts.
Talking about abortion from a medical perspective is challenging when you are not a health care provider. Even someone familiar with the laws can get confused. For example, Mrs. Clinton made an error speaking about late-term abortion when she said it was a health of the mother issue. Typically, it is not (it’s almost always fetal anomalies). However, this error on Clinton’s part only underscores how important it is for politicians to not practice medicine.
To put it in perspective, 1.3 percent of abortions happen at or after 21 weeks and 80 percent are for birth defects. Put another way, 1 percent of abortions that are at or after 21 weeks and are for birth defects and 0.3 percent of abortions are at or after 21 weeks and are not for birth defects (some of these will be health of the mother and a very few will be for other indications). Let’s take it situation by situation.
This could range from Down syndrome to anomalies incompatible with life. The generally accepted limit of viability is 24 weeks. Before that, gestational age abortions can happen for any reason. After 18 or so weeks, the options are an induction of labor or a dilation or an evacuation (or D and E), which is a surgery.
With induction, it can take a few days as labor can be hard to trigger so early. If all goes well, the cervix dilates and the fetus delivers. Sometimes inductions fail because you can’t always get such a premature uterus to contract. With a D and E, the cervix is dilated, with the help of medication, instruments or both, and the fetus is removed. The fetus is essentially taken apart with a D and E to fit through the dilated cervix (the cervix is dilated less with a D and E than for an induction). This is no secret to the women having the procedure. This is also no ripping; there is simply surgical technique. Women know they were pregnant before the procedure and that they were not after ― and trust me, they don’t think their doctor waved a magic wand or had a time turner.
After 24 weeks, birth defects that lead to abortion are very severe and typically considered incompatible with life. These procedures are either a traditional induction, just like labor, or something that requires instrumentation. Because of the nonsensical partial birth abortion law women who wish to have a dilation and extraction (a modified technique for more advanced procedures) need to have fetal cardiac activity stopped with an injection into the uterus. Either way, it’s a two or three (or even four) day process to get the cervix to dilate enough.
The further along in the pregnancy, the more likely the procedure will be an induction of labor. But a skilled practitioner can do a dilation and extraction at 32 or 34 weeks. I’ve never heard of a dilation and extraction for any other reason than severe birth defects, and often, it is for a woman who has had two or three c-sections for whom inducing labor might pose other health hazards, like uterine rupture. Are we to force women to have c-sections for a pregnancy that is not compatible with life?
Why do some women end up with these procedures later on in their pregnancy? Sometimes it can take weeks or even longer to fully understand what is going on with the fetus. Some patients might think they can make it to term and then at 34 weeks cave and ask to be delivered because they just can’t bear one more person asking them about their baby. Do they just smile and walk away or say, “Well, actually, my baby has no brain and will die at birth”? Some women go to term and others can’t. To judge these women for requesting an early delivery is cruel on so many levels. I wrote more about it here if you are interested.
Regardless, terminations for birth defects isn’t ripping “the baby out of the womb in the ninth month.” At 38 or 39 weeks, it’s always an induction and is simply called a delivery.
Health of the Mother
This definitely happens between 20 and 24 weeks. The most likely scenario is ruptured membranes and an infection in the uterus. The treatment of this is delivery or the infection will spread and kill the mother; however, someone with lupus or renal disease or heart disease (for example) could have a deterioration of their health and with their providers make the decision to have a termination.
After 25 weeks, this would simply be a c-section or an induction of labor and the baby would go to the neonatal intensive care unit. Between 24-25 weeks, there could be some leeway as conditions that are serious enough to require delivery at 24 weeks often also have devastating effects on the fetus. For example, the fetus could be so severely growth restricted making viability at 24 weeks unlikely and a woman with a severe heart condition may not elect to risk her health with a c-section for a likely non viable pregnancy and choose a termination.
These are difficult and nuanced decisions, and everyone is simply working together to make the best decision for the pregnant person. I don’t know where Mrs. Clinton got this “bad news at the end” of the pregnancy being about maternal health. I have only ever heard of one very late abortion for maternal health and that was for the rape of a minor by her brother and that was still not at term.
So no one is performing health of the mother abortions at 38 or 39 weeks/ We just do deliveries. It’s called obstetrics.
Some of the 0.3 percent of abortions after 21 weeks will be for personal reasons. Often these are called elective abortions, but I don’t like that term. Usually this happens when it took too long to find a clinic and raise the money. These abortions happen before 24 weeks. There is no ninth month action here either.
There are no ninth month abortions. Really. A ninth month abortion is a unicorn and so it’s ridiculous to even discuss it. Terminations after 24 weeks are for severe fetal anomalies.
If it’s a unicorn, why not legislate it? Introducing a gestational age limit is introducing the thin edge of the wedge. Once you say abortion is illegal at say 37 weeks then you have agreed the subject is up for negotiation and more legislation.
If someone were truly interested in reducing abortion, they wouldn’t start with the 1.3 percent. More reductions can be made in the first trimester where most terminations are due to unplanned pregnancies. These abortions could be reduced dramatically with access to free and accessible long-acting reversible contraception. To dismiss these abortions and focus on the later procedures means it is not about reducing abortion at all, so it can only be about punishment and control.
A version of this post originally appeared on DrJenGunter.wordpress.com.