Likely Ban on Abortion Technique Leaves Doctors Uneasy

NYTimes ^ | 4/22/03 | MARY DUENWALD

[RJCogburn]

As a ban on a procedure that opponents call partial-birth abortion makes its way through Congress, many of the doctors who provide abortions say they remain confused about what will be banned and fear it will apply to other procedures used in the second trimester of pregnancy.

The procedure at issue — what doctors now call intact dilatation and extraction, or intact D&X — involves pulling the fetus's legs and torso out of the uterus and then crushing its skull before removing it entirely. It is not known how often it is performed in the United States, but its use is limited to the latter weeks of the second trimester. Even then, it is not always the procedure doctors choose.

In fact, it is practiced very rarely. Many doctors who perform abortions say they do not use the technique at all. Yet they agree that in certain situations, it may be the safest way to perform an abortion.

"There are times, quite frankly, when this is the procedure of choice," said Dr. Deborah Oyer, a family practitioner in Seattle who provides abortions, but not late enough in pregnancy to practice the method.

Doctors say they fear that even if they give up this particular procedure, the law will still apply to other techniques that are regularly used to end pregnancies after 16 weeks. The law, many experts say, is vaguely written. It does not spell out the intact D&X procedure.

"The way they define the procedure in the bill, it could easily be attributed to a wide variety of abortion procedures," said Dr. Paul D. Blumenthal, an obstetrician-gynecologist at Johns Hopkins University. Even if doctors begin abortions intending to obey the law, he added, they may be forced by medical circumstances to perform procedures that violate it.

Only one abortion provider interviewed for this article acknowledged regularly practicing intact D&X, and she spoke on the condition that her name not be used. Many others interviewed declined to describe their procedures in detail, for fear of being singled out by anti-abortion protesters.

On March 13, the Senate passed a bill outlawing the procedure. The House of Representatives is expected to follow soon, and President Bush has promised to sign the legislation. President Bill Clinton vetoed similar bills in 1996 and 1997.

Over the years, an important question has remained unanswered: how many partial-birth abortions are actually done?

In 2000, the Alan Guttmacher Institute, a research organization that supports abortion rights, surveyed abortion providers nationwide and estimated that 2,200 such procedures were done that year, by 31 physicians. That would account for less than one-fifth of 1 percent of the estimated 1.31 million abortions performed in the United States that year.

But because not all abortion providers answered the survey, the estimate "could be off by a considerable amount," said Stanley Henshaw, a senior fellow at the institute.

Dr. Warren Hern, director of the Boulder Abortion Clinic in Colorado, questioned whether any doctors in the survey were actually using a so-called partial-birth procedure, because no such technique had ever been described in a medical journal. "We have no idea how this is done or even whether it is done," he said. "Until it's published in a peer-reviewed journal, it's folklore."

One aspect of the debate has changed. When it began, some opponents of the ban said the targeted form of abortion was used only when a fetus had extreme abnormalities or a mother's health was endangered by pregnancy. Now, both sides acknowledge that abortions done late in the second trimester, no matter how they are conducted, are most often performed to end healthy pregnancies because the woman arrived relatively late to her decision to abort.

A Guttmacher study from 1987 indicates that only 2 percent of abortions done after 16 weeks of pregnancy are done because of fetal abnormalities.

A vast majority of second-trimester abortions are done using a technique called dilatation and evacuation, or D&E, in which the cervix is dilated, the fetal sac is punctured and drained, and the fetus's head is crushed. Then the body is dismembered and removed. The procedure typically takes less than 10 minutes.

When a pregnancy has advanced beyond 18 weeks, the process can be more complicated. Because the fetus is larger, it may take three or four days to adequately dilate the cervix. Dr. Hern kills the fetus with an injection of the heart drug digoxin a few days ahead of time. After draining the amniotic fluid, he gives the patient ocytocin to cause contractions of the uterus. This movement aids in expelling the fetus.

Second-trimester abortions can also be done by inducing using labor and delivery alone. Fewer than 2 percent are done this way, however, 1999 statistics from the Centers for Disease Control and Prevention show. Physicians largely abandoned the approach after studies in the 1970's indicated that D&E abortions were safer, said Dr. David Grimes, a former chief of the C.D.C.'s abortion surveillance division.

The studies showed that complications — including bleeding and infections — occurred in 25 of every 1,000 abortions done by induced labor but only 7 of 1,000 abortions done by D&E.

Dr. George R. Tiller of Wichita, Kan., who uses a labor-and-delivery technique, injects the fetus with digoxin one to four days ahead of time. The kind of abortion that would be banned under the new law is a variation of D&E. It was first described by an Ohio doctor in the early 1990's, in a talk to the National Abortion Federation. After his description set off a debate, the American College of Obstetrics and Gynecology described a similar technique, and called it intact D&X.

The technique was designed for abortions done after 18 to 20 weeks, when the fetus's head has grown too large to fit through the cervix easily. By 20 weeks, a fetus is typically about eight inches long.

The physician reaches into the uterus to turn the fetus into a feet-first position. The fetus is pulled through the cervix up to the neck. The doctor then pierces the fetal skull with an instrument and drains some of its contents. This causes the skull to collapse and fit through the opening.

Some doctors do an intact D&X without first adjusting the fetus to a feet-first position, so that it may come out head first.

"From the time I first saw it done, it was clear to me that this procedure was safer and faster and better than the abortions I had been doing before," said the abortion provider who regularly practices intact D&X. The advantage, she said, is that it involves less poking and jabbing inside the uterus.

Rather than mentioning intact D&X, the bill describes a situation in which a doctor "deliberately and intentionally vaginally delivers a living fetus" until either the head or the body up to the navel is "outside the body of the mother" and then intentionally kills it.

Dr. Curtis R. Cook, a maternal fetal medicine specialist at Spectrum Health in Grand Rapids, Mich., who helped write the law, said he avoided the College of Obstetrics and Gynecology's description of intact D&X so that the law would apply to any abortion in which a live fetus is brought partway out of the uterus, not only to those that follow the college's description to the letter.

Abortion providers say that in some classic D&E operations, part of the fetus may pass through the cervix while it is still alive.

"If the cervix is more dilated than you expect, sometimes a large part of the fetus will come out at a variety of gestational ages, from 15 to 22 weeks," explained the physician who practices intact D&X. "If the fetus comes halfway out, and then you do something to complete the abortion, that would be against the law as they've written it. What would you do then? Try to put the fetus back in?" The physician is usually relieved when a large part of the fetus drops into the vagina, she said, because "it means the fetus is coming out in a more gentle and rapid manner."

Because it is hard to know if a fetus is dead or alive, said Dr. Phillip Stubblefield, director of obstetrics and gynecology at Boston Medical Center, "almost any D&E you do from 13 or 14 weeks on, you're going to violate the statute."

But Dr. Cook said the law would not affect D&E abortions. "We used very clear language," he said. "It has to be an overt act, not an unintentional act."

Dr. Nancy Romer, an obstetrician in Dayton, Ohio, who also favors the ban, said abortion providers could comply with the proposed law by killing the fetus with an injection before starting the abortion. "It adds no additional risk, and it gets around the whole issue," she said.

Abortion providers argue that an injection does make the operation riskier because it involves putting drugs in the uterus, and it requires passing a needle through the woman's abdomen.

Dr. Stubblefield noted that the technique was the same one used to perform amniocentesis in pregnancy, in which doctors pass a needle into the amniotic sac to draw fluid for genetic testing. "It can be tricky," he said. "Every now and then one goes through a loop of bowel with the needle. You can carry bacteria in the uterus, and that can lead to severe sepsis."

If this step is routinely added to the standard abortion, he said, "we'd be exposing a whole lot of women to a risk they don't need to be taking."

The ban before Congress includes an exception for saving the life of the mother, but not for preserving her health because, the bill asserts, "a partial-birth abortion is never necessary to preserve the health of a woman."

Most abortion providers disagree. Dr. Tiller of Wichita said intact D&X might be the safest procedure for some physicians.

"It doesn't fit my style of practice," Dr. Tiller said, "but there are good practitioners who develop different styles. If you force those physicians to use my technique, they will not get results as good."

In certain situations related to a mother's dangerously high blood pressure, removing the fetus quickly may be desirable, Dr. Oyer of Seattle said. In such a case, intact D&X might be fastest, she said.

Dr. Cook argued that induced labor would be faster because the patient would not have to wait two days for the cervix to dilate. The so-called partial-birth abortions, he said, can "overdilate" the cervix. "Women who have had this procedure have had problems with cervical incompetence afterward," he added.

When physicians cut into fetal skulls in intact D&X procedures, he added, they risk tearing or cutting the uterus.

Dr. Grimes disagreed with both assertions. "There's not a bit of documentation to establish that intact D&X carries these risks, and I would challenge them to provide a citation anywhere," he said.

A question that often enters the debate is whether the fetus senses pain in an intact D&X abortion.

"We can say with confidence the fetus does not feel pain," Dr. Grimes said. "Neurologically, it is not developed enough to feel pain. A fetal brain in mid-trimester doesn't even look like a human brain. The neural pathways aren't there."

Ultimately, the abortion providers say that they should be able to choose the procedure that is best for each patient.

"The goal of any abortion procedure is the destruction of the fetus," said Dr. Felicia H. Stewart of the University of California at San Francisco. "Given that that is the reality, it doesn't seem to me we ought to have a legislative mandate that likely increases the risk to the woman."

[MHGinTN]

You should see the expressions on teen faces when I've described the various methods of killing the preborn, after I have given them clear descriptions of the gestational stages and the level of sensing that babies at 14 to 16 weeks from conception have. I used to give presentations to High Schoolers, but political correctness now eliminates even the most non-biased presentations to these young people. They are left to learn from sex ed classes (totally twisted, agenda laden curricula) and PP 'counselors'; very few learn of these horrific truths from their parents.

[Luis Gonzalez]

I can't bear to read these things, I just can't.

I can't imagine for the life of me civilized people sitting around a table discussing the most feasible way to do this.

I wonder if we are lost.

[Luis Gonzalez]

I just FReemailed you a link.

I wonder how much of this we have brought down on our own heads.

[sport]

As a ban on a procedure that opponents call partial-birth abortion makes its way through Congress, many of the doctors who provide abortions say they remain confused about what will be banned and fear it will apply to other procedures used in the second trimester of pregnancy.

No, the ban does not make any doctors uneasy.

It may make some medical butchers or legal murderers uneasy, but it does not make any medical doctors uneasy

[sport]

.....Many doctors who perform abortions ....

A doctor will not perform an abortion.

A murderer or butcher who is liscensed to practice medicine may perform an abortion, but a bona fide doctor, never.

[MHGinTN]

I do not doubt it, my friend: 'Whatsoever ye sow that shall ye also reap.'

[Southack]

"I wonder if we are lost."

No, I don't think that we are lost.

Roe v Wade was thrust upon us by an activist Court, *not* by a popular vote. That decision, weak as it is in Constitutional and logical basis, overrode the votes of the majority of Americans in a majority of our states (i.e. those states that had bans on abortion in place).

In contrast, a "lost" society would have never freely voted for those bans, but rather for their opposites.

Thus, our society is not lost, and we will demonstrate that fact again by voting in a ban on this partial birth abortion procedure this year.

...And if the Left overturns this ban, their precedent will likewise overturn Roe v Wade, sending the authority to ban abortions back to the states where it should have always remained, and in these states the good people will again vote to not be "lost".

[Southack]

"You should see the expressions on teen faces when I've described the various methods of killing the preborn..."

First show a woman a sonagram of her baby and you she will stop the VAST majority of all abortions.

One of the things that we can do to change hearts and minds is to finance as many sonagram machines in as many public places as possible.

I'd like to see free sonagrams given away daily in every public shopping mall in America, for starters.

Passing these bans on various abortion procedures is fine, and probably our duty, but changing hearts and minds is even better.

You know, I've seen threads here on FR where posters want to raise enough money to "sponsor" a MOAB for Iraq or a BLU-82 daisy cutter for Afghanistan in Free Republic's name, but given the choice, I'd rather have a Free Republic sonagram machine in a shopping mall.

[Luis Gonzalez]

You can't blame it on Roe v. Wade...it's an inanimate object, a bad idea, but in and of itself harmless...unless acted upon.

If our society was different, if we were different, all the Roe v. Wades in the world would not mean a thing, because there wouldn't be any abortions.

Would you have an abortion?

[Southack]

Good point, but by your point our society is clearly not lost, as far fewer than 1% of our population are having abortions, so our society as a whole is not lost, but rather, we need to work on changing hearts and minds in that sub-1% group.

[nickcarraway]

Why did they bother having a reporter waste time writing this article, when the could have printed the Planned Parenthood press release, without the minor changes?

[nickcarraway]

Actually, the Guttmacher Institute is a division of Planned Parenthood. (the reasearch arm, to be exact) So the money that funds their very existence is made on abortions. You would think a journalist may have wanted to mention that.

[shhrubbery!]

Someone I know had this procedure done at the very last week that it is legal.

All abortions are legal throughout pregnancy. There is no point at which any abortion is illegal, in any state.

Roe v. Wade ruled that states may "regulate" abortions in the last trimester. E.g., states can require that third trimester abortions must be performed in hospitals and not in doctors' offices.

However, states are NOT allowed to ban any kind abortion at any stage of pregnancy, if the mother's "HEALTH" is at risk. This was established by Roe's companion case, Doe v. Bolton.

And "health" of course can mean anything, from a hangnail to feeling kinda blue about being pregnant.

[Eagle Eye JR]

A vast majority of second-trimester abortions are done using a technique called dilatation and evacuation, or D&E, in which the cervix is dilated, the fetal sac is punctured and drained, and the fetus's head is crushed. Then the body is dismembered and removed. The procedure typically takes less than 10 minutes.

This is disgusting, I don't know how any human being could do something like this. IMHO these people are serial killers and should be treated as such.

[supercat]

A murderer or butcher who is liscensed to practice medicine may perform an abortion, but a bona fide doctor, never.

What would a doctor do if he diagnosed a pregnant patient of his with cancer that is at severe risk of spreading?

To be sure, a woman so diagnosed should have the option of continuing the pregnancy if she's willing to accept the risk of delaying cancer treatment, but if a woman decides she wants immediate treatment at the expense of the fetus, what would a doctor do?

[votelife]

Here is a recent email I sent to W.

Dear President Bush, With the Surpeme Court session getting ready to close, it may well be time for perhaps the most important domestic decision of your presidency: the appointment of a Supreme Court Justice(s). The main reason why I supported you in 2000 and why I wanted Daschle out of power in 02 (and 04) has to do with the courts. I want America courts to interpret law, not write law. During your presidential campaign you said Thomas and Scalia were your two model justices. Those are excellent models. The High Court needs more like them. Clarence Thomas recently said to students that the tough cases were when what he wanted to do was different from what the law said. And he goes by the law. This should be a model philosophy for our justices. Your father, President Bush lost his reelection campaign for 3 main reasosn, as far as I can see. 1. he broke the no new taxes pledge 2. David Souter 3. Clinton convinced people we were in a Bush recession (which we had already come out of by the time Clinton was getting sworn in)

I urge you to learn from all three of these: 1. on taxes, you're doing great. Awesome job on the tax cut. 2. good job so far on judicial appointments. I want to see more of a fight for Estrada, Owen, and Pickering, but I commend you on your nominations. 3. by staying engaged in the economic debate you'll serve yourself well

I have been thoroughly impressed with your handling of al Queida, Iraq, and terrorism. You have inspired confidence and have shown great leadership.

But I want to remind you that your Supreme Court pick(s) will be with us LONG after you have departed office. I urge you to avoid the tempation to find a "compromise" pick. Go for a Scalia or Thomas. Don't go for an O'Connor or Kennedy. To be specific, get someone who is pro-life. Roe v Wade is one of the worst court decisions I know of, and it's the perfect example of unrestrained judicial power.

I know the temptation will be tremendous on you to nominate a moderate. But remember who your true supporters are. I am not a important leader or politician. I am "simply" a citizen who has been an enthusiatic supporter of you. I am willing to accept compromise in many areas of government but I will watch your Court nomiantions extremely closely. What the Senate Dems are doing right now is disgusting, but as the President you have the bully pulpit to stop it. Democrats will back down if you turn up serious heat on them.

Moreover, I think public opinion is shifting towards the pro-life position. Dems will want you to nominate a moderate, but almost all will vote against you anyways. Pro-choice Repubs will likely still vote for you if you nominate a Scalia, after all, you campaigned on it. So Mr. President, I urge you to stick with your campaign statements and nominate justices who believe in judicial restraint, like Scalia and Thomas.

Happy Memorial Day and may God bless you and your family.