Late termination of pregnancy
|Late termination of pregnancy|
|Other names||Postviability abortion, third trimester abortion, induced termination of pregnancy (ITOP), late-term abortion|
|Specialty||Obstetrics and gynecology|
Late termination of pregnancy (referred to as late-term abortion by anti-abortion advocates) describes the termination of pregnancy by induced abortion during a late stage of gestation. "Late", in this context, is not precisely defined, and different medical publications use varying gestational age thresholds. In 2015 in the United States, about 1.3% of abortions took place after the 21st week, and less than 1% occur after 24 weeks.
The most common reason for late terminations of pregnancy is when a pregnant woman's health is at serious risk or when lethal fetal abnormalities have been detected. These anomalies may include anencephaly or limb-body wall complex where death occurs almost immediately after birth. Other common factors include not recognizing pregnancy until after the first trimester, needing more time to make a decision about a pregnancy, or legal restrictions that prevent women from obtaining an abortion earlier in pregnancy. Later abortion is not associated with any negative physical or mental health outcomes, and the risk of death following a surgical abortion after 20 weeks is less than that of typical full-term childbirth in the United States.
Late termination of pregnancy is more politically controversial than abortion in general. Most countries in Europe permit abortion in later stages of pregnancy if specific circumstances are present. The American College of Obstetricians and Gynecologists states with respect to abortion that "politicians should never interfere in the patient-physician relationship".
A late termination of pregnancy often refers to an induced ending of pregnancy after the 20th week of gestation, i.e. after a fetal age (time since conception) of about 18 weeks. The exact point when a pregnancy becomes late-term, however, is not clearly defined. Some sources define an abortion after 16 weeks as "late".  In three articles published in 1998 in the same issue of the Journal of the American Medical Association (JAMA) two chose the 20th week of gestation and one chose the 28th week of gestation as the point where an abortion procedure would be considered late-term.
The point at which an abortion becomes late-term is often related to the "viability" (ability to survive outside the uterus) of the fetus. Sometimes late-term abortions are referred to as post-viability abortions, though this is not a medical term.
There is no sharp limit of development, age, or weight at which humans automatically become viable. According to studies between 2003 and 2005, 20 to 35 percent of babies born at 23 weeks of gestation survive, while 50 to 70 percent of babies born at 24 to 25 weeks, and more than 90 percent born at 26 to 27 weeks survive. It is rare for a baby weighing less than 500 g (17.6 ounces) to survive. A baby's chances for survival increases 3-4% per day between 23 and 24 weeks of gestation and about 2-3% per day between 24 and 26 weeks of gestation. After 26 weeks the rate of survival increases at a much slower rate because survival is high already.
Due to the potential of signs of life in a non-viable fetus—and the corresponding legal implications—most experts recommend induced fetal demise for abortions after 18 to 20 weeks gestation. The International Federation of Gynecology and Obstetrics states that abortions "after 22 weeks [gestation] must be preceded by feticide." If medical staff observe signs of life, they may be required to provide care: emergency medical care if the child has a good chance of survival and palliative care if not.
A wanted abortion in any trimester is not associated with mental health harms. Overall, abortion does not increase the risk of experiencing symptoms of depression, anxiety or stress in the short term or over five years. A previous history of mental health conditions, sexual assault, and intimate partner violence were strongly associated with experiencing negative mental health outcomes after the abortion.
- Australia: As of 2015[update], South Australia is the only Australian state or territory to keep reliable abortion statistics. During 2012, 92% of abortions were performed before 14 weeks' gestation, 6% between 14–20 weeks, and 2% (n=96) at a later stage. Of the 96 abortions carried out beyond 20 weeks, 53 were due to actual or probable fetal abnormality.
- Canada: During the year 2009, 29% of induced abortions were performed before 8 weeks, 41% at 9 to 12 weeks, 7% at 13 to 16 weeks and 2% over 21 weeks.
- England and Wales: In 2015, 8% of abortions occurred after 12 weeks; 0.1% occurred at or over 24 weeks.
- New Zealand: In 2003, 2.03% of induced abortions were done between weeks 16 and 19, and 0.56% were done over 20 weeks.
- Norway: In 2005, 2.28% of induced abortions were performed between 13 and 16 weeks, 1.24% of abortions between 17 and 20 weeks, and 0.20% over 21 weeks. Between February 15, 2010 and December 1, 2011, a total number of ten abortions were performed between 22 and 24 weeks. These have been declared illegal by The Norwegian Directorate of Health.
- Scotland: In 2005, 6.1% of abortions were done between 14 and 17 weeks, while 1.6% were performed over 18 weeks.
- Sweden: In 2005, 5.6% of abortions were carried out between 12 and 17 weeks, and 0.8% at or greater than 18 weeks.
- United States: In 2003, from data collected in those areas that sufficiently reported gestational age, it was found that 6.2% of abortions were conducted between 13 and 15 weeks, 4.2% between 16 and 20 weeks, and 1.4% at or after 21 weeks. In 2014, the CDC reported that 1.3% of reported abortions (5,578) were performed at 21 weeks of gestation or later.
Late-term abortions usually take place when the mother's health is at serious risk or when fatal abnormalities have been detected.
A study from 2013 found after excluding abortion "on grounds of fetal anomaly or life endangerment", that women seeking late abortions "fit at least one of five profiles: They were raising children alone, were depressed or using illicit substances, were in conflict with a male partner or experiencing domestic violence, had trouble deciding and then had access problems, or were young and nulliparous". They concluded that "bans on abortion after 20 weeks will disproportionately affect young women and women with limited financial resources".
England and Wales
The NHS records the reasons given for abortions at all stages of development. In 2015, 2,877 abortions were performed at 20 weeks or above. Of these, 23 (0.8%) were performed to save the life of the pregnant woman, 1,801 (63%) were performed for mental or physical health reasons, and 1046 (36%) were performed because of foetal abnormalities. 
As of 1998, among the 152 most populous countries, 54 either banned abortion entirely or permitted it only to save the life of the pregnant woman.
On the other hand as of 1998, 49 of the 152 most populous countries allowed abortion without restriction as to reason, but 44 of these required specific justification after a particular gestational age:
- 12 weeks (Albania, Armenia, Azerbaijan, Belarus, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Cuba, Czech Republic, Denmark, Estonia, France, Georgia, Greece, Kazakhstan, Kyrgyz Rep., Latvia, Lithuania, Moldova, Mongolia, Norway, Russian Federation, Saudi Arabia, Slovakia, Slovenia, South Africa, Ukraine, Tajikistan, Tunisia, Turkey, Turkmenistan and Uzbekistan)
- 13 weeks (Italy)
- 14 weeks (Austria, Cambodia, Germany, Hungary, Romania and Spain)
- 18 weeks (Sweden)
- 22 weeks (North Macedonia)
- 24 weeks (Singapore)
- viability (Netherlands and to some extent the United States)
- no limit (Canada, some states in the United States, China, and North Korea)
As of 2011 among those countries that allowed abortion without restriction as to reason, the gestational limits for such abortions on request were: 37 countries set a gestational limit of 12 weeks, 7 countries of 14 weeks, 4 did not set limits, 3 at viability, 3 at 10 weeks, one at 90 days, one at 8 weeks, one at 18 weeks, and one at 24 weeks. In addition, Abortion in Australia, and, to a certain extent, Abortion in the United States, is regulated at state/territory level, and laws vary by region.
In these countries, abortions after the general gestational age limit are allowed only under restricted circumstances, which include, depending on country, risk to the woman's life, physical or mental health, fetal malformation, cases where the pregnancy was the result of rape, or poor socio-economic conditions. For instance, in Italy, abortion is allowed on request up until 90 days, after which it is allowed only if the pregnancy or childbirth pose a threat to the woman’s life, a risk to physical health of the woman, a risk to mental health of the woman; if there is a risk of fetal malformation; or if the pregnancy is the result of rape or other sexual crime. Denmark provides a wider range of reasons, including social and economic ones, which can be invoked by a woman who seeks an abortion after 12 weeks. Abortions at such stages must in general be approved by a doctor or a special committee, unlike early abortions which are performed on demand. The ease with which the doctor or the committee allows a late term abortion varies significantly by country, and is often influenced by the social and religious views prevalent in that region.
Some countries, like Canada, China (Mainland only) and Vietnam have no legal limit on when an abortion can be performed.
As of December 2014, forty-two states had bans on late-term abortions that were not facially unconstitutional under Roe v. Wade or enjoined by court order. In addition, the Supreme Court in the case of Gonzales v. Carhart ruled that Congress may ban certain late-term abortion techniques, "both previability and postviability", as it had done in banning intact dilation and extraction with the Partial-Birth Abortion Ban Act of 2003.
The Supreme Court has held that bans must include exceptions for threats to the woman's life, physical health, and mental health, but four states allow late-term abortions only when the woman's life is at risk; four allow them when the woman's life or physical health is at risk, but use a definition of health that pro-choice organizations believe is impermissibly narrow. Note that just because a portion of a state's law is found to be unconstitutional does not mean that the entire law will be deemed unconstitutional: "[I]nvalidating the statute entirely is not always necessary or justified, for lower courts may be able to render narrower declaratory and injunctive relief," meaning the court could declare that only those parts of the law that are violative of the Constitution are invalid (declaratory relief), or that the court can prohibit the state from enforcing those portions of the law (injunctive relief).
Eighteen states prohibit abortion after a certain number of weeks' gestation (usually 22 weeks from the last menstrual period). The U.S. Supreme Court held in Webster v. Reproductive Health Services that a statute may create "a presumption of viability" after a certain number of weeks, in which case the physician must be given an opportunity to rebut the presumption by performing tests. Because this provision is not explicitly written into these state laws, as it was in the Missouri law examined in Webster, pro-choice organizations believe that such a state law is unconstitutional, but only "to the extent that it prohibits pre-viability abortions".
Ten states (although Florida's enforcement of such laws are under permanent injunction) require a second physician's approval before a late-term abortion can be performed. The U.S. Supreme Court struck down a requirement of "confirmation by two other physicians" (rather than one other physician) because "acquiescence by co-practitioners has no rational connection with a patient's needs and unduly infringes on the physician's right to practice". Pro-choice organizations, such as the Guttmacher Institute, posit that some of these state laws are unconstitutional, based on these and other Supreme Court rulings, at least to the extent that these state laws require approval of a second or third physician.
Thirteen states have laws that require a second physician to be present during late-term abortion procedures in order to treat a fetus if born alive. The Court has held that a doctor's right to practice is not infringed by requiring a second physician to be present at abortions performed after viability in order to assist in the case of a living fetus.
There are at least four medical procedures associated with late-term abortions:
- Dilation and evacuation (D&E)
- Early labor induction (sometimes called "induction abortion")
- Intact dilation and extraction (IDX or D&X), sometimes referred to as "partial-birth abortion"
- Hysterotomy abortion
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Late-term abortion is a phrase used by abortion opponents to refer to abortions performed after about 21 weeks of pregnancy. It is not the same as the medical definition obstetricians use for 'late-term,' which refers to pregnancies that extend past a woman’s due date, meaning about 41 or 42 weeks.
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Abortions after 24 weeks comprise less than one percent of all abortions. When they occur, it is usually because the fetus has been found to have a fatal condition that could not be detected earlier, such as a severe malformation of the brain, or because the mother’s life or health is at serious risk.
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Inducing fetal demise before induction termination avoids signs of live birth that may have beneficial emotional, ethical and legal consequences.
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“Partial-birth” abortion bans—The federal Partial-Birth Abortion Ban Act of 2003 (upheld by the Supreme Court in 2007) makes it a federal crime to perform procedures that fall within the definition of so-called “partial-birth abortion” contained in the statute, with no exception for procedures necessary to preserve the health of the woman...physicians and lawyers have interpreted the banned procedures as including intact dilation and evacuation unless fetal demise occurs before surgery.
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With medical abortion after 20 weeks of gestation, induced fetal demise may be preferable to the woman or provider in order to avoid transient fetal survival after expulsion.
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Transient survival with misoprostol for labor induction abortion at greater than 18 weeks ranges from 0% to 50% and has been observed in up to 13% of abortions performed with high-dose oxytocin.
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... following later abortions at greater than 20 weeks, the rare but catastrophic occurrence of live births can lead to fractious controversy over neonatal management.
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Termination of pregnancy following prenatal diagnosis after 22 weeks must be preceded by a feticide
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The term ``born alive is defined as the complete expulsion or extraction from its mother of that member, at any stage of development, who after such expulsion or extraction breathes or has a beating heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, regardless of whether the umbilical cord has been cut, and regardless of whether the expulsion or extraction occurs as a result of natural or induced labor, cesarean section, or induced abortion.
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