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The murder of Dr. George Tiller was a horrible and vicious act on a man who did so much good for women and saved countless lives. Dr. George Tiller was murdered because he provided late term abortions, which occured late in pregnancy but  were still desperately needed. If there is one glimmer of hope in the tragedy of Dr. Tiller’s murder it would be the introspection and dialogue it has created over the controversial topic of late term abortion. Abbey924 cited the need for reproductive health activists, feminists and generally liberal people to be more vocal about their support of abortion…even late term abortion. This point is definitely powerful considering how agressively the other side supports limiting abortion rights.

For some, late term abortion is a contentious topic, even in the liberal community. Regardless of your stance however its important for more people to understand late-term abortions: how often do they occur, why women get them and why women should continue to have a right to this procedure.

What is a late term abortion?

There is no exact definition of late term abortion. There are different definitions depending on context and who is asked. This article from the Dallas Morning News, defines it in the following ways:

The most conservative definition says any abortion after 12 weeks of gestation is late-term. Others say only abortions performed after fetal viability, which means the ability of the fetus to survive outside the uterus, should be defined as late-term. Generally, viability begins between the 22nd and 27th week of pregnancy.

The actual procedure is quite painful:

The most common process is called dilation and extraction. A doctor inserts laminaria sticks into the woman’s cervix. These sticks, often made from a species of kelp, absorb liquid and expand. This dilates the cervix and promotes labor. The doctor injects a chemical into the amniotic cavity to kill the fetus and extracts the remains with surgical instruments.

How many late term abortions are actually provided?

     Not many late term abortions are actually provided because they are strictly limited by the Roe vs Wade Supreme Court decision via state law. Firstly about 89% of abortions occur before 12 weeks so even according to the most conservative estimates only 11% of abortions would be considered late term. However if we use the viability standard of 22- 27 weeks, less than 1.1% of abortions would occur after this point. 

What are the limitations on late term abortions?

  According to this nice summary from Reproductive Health Reality Check federal and state laws severely restrict late term abortions. Most late term abortions never happen because of Supreme Court decisions in Roe vs Wade (1973) and Gonzales vs Cahart (2007) have severely limited late term abortions and the Partial Birth Abortion act (2007) which is still upheld which bans late term abortion. There is debate as to how many women recieve elective (non health related) late term  abortions for reasons related to the health of the mother or fetus vs how many late term abortions are performed on healthy fetuses and healthy mothers. After all, the image of a carefree late term abortion can be controversial even to some within the pro-choice movement. Since late term abortion is so closely regulated it would seem that the image of a woman waking up in her 24 week and deciding to have an abortion on a whim is quite rare because she most likely would not be legally able to obtain a legal abortion.

What are the reasons that women seek late term abortions? Is it just casual whim or is it serious medical conditions and the safety of the mother and fetus or perhaps something else?

  There are no widely recognized data on why women seek late term abortions because they are not required to report the reason they seek the abortion on medical documentation. Besides just medical reasons such as the compromised health of the mother or fetus, the Guttmacher institute lists the following as reasons that women cited for abortions according to their research:

 The reasons women give for having an abortion underscore their understanding of the responsibilities of parenthood and family life. Three-fourths of women cite concern for or responsibility to other individuals; three-fourths say they cannot afford a child; three-fourths say that having a baby would interfere with work, school or the ability to care for dependents; and half say they do not want to be a single parent or are having problems with their husband or partner.

  Most states leave it up to the physician to determine if a situation meets the critiera for a late term abortion such as: preserving the life and health (physical and mental) of the mother or if the infant would not otherwise be viable. So one should realize according to this criteria and the strict legal restrictions on late term abortions that there are probably extremely few cases in which a woman wakes up one day in her 24th week of pregnancy and decides to get an abortion especially considering that it is a painful surgical procedure.

   According to the highly respected, Journal of the American Medical Association (JAMA), most late term abortions are not on whim and infact: 

"Women who have late abortions often are disadvantaged. Teenagers, especially those younger than 15 years, and women of minority status disproportionately have late abortions.3 Many of these patients either do not suspect the pregnancy or attempt to conceal it until the pregnancy becomes evident. Menstrual irregularity is an important risk factor.10 Women with irregular menses often discover late that they are pregnant. Other risk factors include young age, low educational attainment, having had a sexually transmitted disease, and ambivalence about the decision to abort.11 Thus, many of the factors associated with late abortions are not easily changed.

Women seeking late abortions are often disadvantaged in other ways, such as lack of knowledge about options, lack of money to pay for the procedure, lack of transportation to a provider, and alcohol or other drug dependence. Some young women are unaware of the availability of late abortions. Since enactment of the Hyde Amendment, the federal government has not paid for indigent women to have abortions, and few states subsidize abortion services. Hence, some women need weeks to raise the money to pay for an abortion, which delays the procedure until the second trimester. Of note, states that fund abortions have significantly lower rates of teen pregnancy, low-birth-weight babies, premature births, and births with late or no prenatal care than do other states.

Geography poses yet another barrier: more than 80% of US counties do not have an abortion provider. Providers of late abortion are even more scarce. In 1993, only 13% of US abortion providers offered abortions at 21 weeks, and the cost averaged more than $1000.12"

Furthermore, there are many health related reasons cited by this JAMA article as to why a woman would need a late term abortion:

Late abortions are fundamentally important to women’s reproductive health.1 Antenatal fetal diagnosis, such as maternal {alpha}-fetoprotein screening and amniocentesis, is predicated on the availability of induced abortion. Although techniques such as chorionic villus sampling and early amniocentesis have allowed earlier diagnosis, by the time results of midtrimester amniocentesis or ultrasound are available, a woman may be beyond 20 weeks’ gestation.13

Illnesses of women and fetal anomalies lead to requests for late abortions. Late abortion can be lifesaving for women with medical disorders aggravated by pregnancy.17 Conditions such as Eisenmenger syndrome carry a high risk of maternal morbidity and mortality in pregnancy, the latter ranging from 20% to 30%.18 In recent years, I have performed late abortions for a Kampuchean refugee with craniopagus conjoined twins and a 25-year-old woman with a 9 x 15-cm thoracic aortic aneurysm from newly diagnosed Marfan syndrome. Cancer sometimes makes late abortion necessary. For example, either radical hysterectomy or radiation therapy for cervical cancer before fetal viability involves abortion.

Incest and rape are other compelling indications. Pregnancies resulting from incest among young teenagers or among women with mental handicaps may escape detection until the pregnancy is advanced. Approximately 32000 pregnancies result from rape each year in the United States; about half of rape victims receive no medical attention, and about one third do not discover the pregnancy until the second trimester.19

GIven that some healthy women with health fetuses, would get an elective, abortion (for a reason unrelated to health), should we still make late term abortion legal?

Yes.  One could argue that just having the legal option of a late term elective abortion is important to protect those women who may not have an explicit physical or mental reason/ fetal viability issue but still because of trauma, youth or poverty simply not carry a pregnancy to term. In this case we must also think, what are our other options….unsafe abortion by amatuers rather than physicians. History has shown that we will not deter women from attempting abortion. Whose life is worth more-(1) the mother who has to choose between being forced to carry an  unintended pregnancy  to term or choose an unsafe abortion that she may die from — or (2) the aborted fetus who never had a chance to live? Whose choice is this to make-society/the state or each individual women who is ultimately the one affected by this choice? Do we believe that a woman should have the power to have input on what occurs in her own body and in her own life and does this right extend to the fetus that is apart of her body?

I think the JAMA article summarized this quite nicely in its conclusions: 

… "The three leading principles of bioethics—respect for persons, beneficence and justice—together provide an ethical mandate for guaranteeing to women throughout the world a legal right to safe abortion." This mandate is especially important for the immature, disadvantaged, and often seriously ill women requesting late abortions in the United States. Regardless of political views on abortion, the scientific evidence is clear and incontrovertible: legal abortion, including late abortion, has been a resounding public health success.

Early abortion is safer, simpler, and less controversial than late abortion. Improving sex education, promoting access to safe and effective contraception, and removing economic and geographic barriers to early abortion can help to reduce the number of late abortions. This is a goal around which there should be broad consensus. Nevertheless, as experience has revealed,3 the need for late abortion will not disappear. Hence, our continuing responsibility as physicians and as a society is to ensure that these procedures are as safe, comfortable, and compassionate as possible. Women deserve no less from their physicians.

TAKE ACTION: 
1. Reproductive Health Reality Check Post on Late Term Abortion

2. From RH Reality Check: Two of the funds available in memory of Dr. Tiller include:

George Tiller Memorial Abortion Fund
c/o National Network of Abortion Funds

42 Seaverns Ave.
Boston, MA 02130

Or you may donate to the Tiller Memorial Fund at NNAF online.

The Women’s Reproductive Rights Assistance Project is also accepting donations in Dr. Tiller’s name.  

3. Journal of the American Medical Association (JAMA),  article on the need for late term abortions:
David A. Grimes
The Continuing Need for Late Abortions
JAMA, Aug 1998; 280: 747 – 750.

4.Here is one woman’s story about her late term abortion.

5. Research facts and statistics on Induced Abortion for the Guttmacher Institute

6. Slate.com article on scandals about late term abortion statistics and  the philsophical underpinnings of this debate

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