Monday, November 10, 2008

Hospital Document Sheds Light on 3rd Trimester Abortions in Quebec

It is inevitable that in every online debate, some proponent of legal abortion will assert that third trimester abortions are illegal in Canada.

Of course, you challenge them to point to the law that says this. And being lazy, they simply make the re-assertion.

Well guess what? Third trimester abortions are legal in Canada. This document is proof. It is a report from the Bioethics Committee at Ste. Justine Hospital in Montreal. The title is: Interruption de grossesse du troisième trimestre pour anomalie fœtale. Or Third Trimester Abortion for Fetal Anomaly. It was published in January 2007. I decided to blog an off-the-cuff summary of the report, underscoring the most relevant information.It’s a long blogpost, but there is a lot of good information.

An interesting thing about the cover on the report. The report is about third trimester abortion, but the cover features a 10-week-old fetus.

The report was created in order to set guidelines for an institutional policy on the practice. The questions asked by the committee were:

Is it ethically acceptable to perform an abortion for fetal anomaly past the threshold of viability?

If yes, what should be the guidelines for this practice?

To answer these questions, the document explores many issues. The first one it addresses is terminology. French is rich in terminology for abortion. There is “interruption volontaire de grossesse” (IVG) which your run-of-the-mill abortion. Then there’s “interruption médical de grossesse » (IMG) which is an abortion with an underlying medical basis. And, a new one for me “Interruption thérapeutique de grossesse” (ITG) which is a medical abortion; sometimes used interchangeably with IMG, sometimes in situations where the mother’s health is at stake, and sometimes where there is a problem with the fetus.

The document specifies that the term “IVG” is preferred because it is less emotionally charged than “abortion”.

Now why would that be?

The next issue they explore is viability. The document clearly states:

Dans notre société, on effectue des interruptions de grossesse du troisième trimestre même lorsque le foetus est viable, ce qui soulève certaines préoccupations

Translation :
In our society, third trimesters are performed even when the fetus is viable, which raises certain concerns.

The report goes on to say that it went to interview the head of the Committee of prenatal diagnostics and the head of the Department of Obstetrics-Gynecology. They were the ones who made the request for the report. They informed the committee about the circumstances of third trimester abortions at the hospital. They went on to interview various other professionals affected by this practice.

They also spoke with social workers who had referred adolescent girls to get third trimester abortions in the United States.

The Committee also spoke with professionals who gathered together services in relation to third trimester abortions to provide a framework for the practice. The Committee also commended the hospital for having in place a palliative care service for the children of mothers who did not go through with the abortion.

Great idea. Now why couldn’t they push that instead of abortion?

The Committee met once in 2004 and once in 2005 to discuss contentious issues in order to reach a consensus. The final report was begun in autumn 2006.

The Abortion Situation at Ste. Justine Hospital

The document relates that Ste. Justine hospital essentially does abortions on teenagers in the first and second trimester, regardless of their reasons. After 20 weeks (LMP—that’s 18 weeks gestation), if the abortions are not of a medical nature, they are referred to other establishments. Some Quebec establishments perform abortions up to the 22nd week (LMP). If the pregnancy has progressed beyond that stage, the mother is sent to either New York State or Kansas. (And we all know that it’s Tiller’s clinic in Wichita that does late-term abortions).

In Montreal, it is the CLSC des Faubourgs that is responsible for co-ordinating and directing girls to US Clinics. The Ministry of Health and Social Services reserves a budget to cover the costs of these trips for the whole province. This budget must be used to cover the cost of terminating the pregnancy, according to the gestational age and the technique used. However, if the woman is too poor, the government will pay for food, lodging and transportation. The budget for incidental expenses—food, taxi, medicine—is $375.

At. Ste. Justine, they consider 24 weeks to be the threshold of viability. Third Trimester abortions can be requested at Ste. Justine, if there is a fetal anomaly.

There are many reasons why third trimester abortions are sought. Sometimes the fetal anomaly is only suspected in the second trimester, but confirmed in the third trimester. Some fetal anomalies only appear in the third trimester by their nature. Sometimes, it’s a question of “wait-and-see” to develop a prognosis. There may also have been a false negative in the earlier stages of the pregnancy. And sometimes a couple that has received news of a fetal anomaly in the second trimester only decides to terminate in the third trimester.

The Committee for fetal and neonatal death examines all files regarding third trimester abortions, and it asserts that almost all of them were due to a medical nature. (“Almost all”—I like that. I’d be interested in knowing which ones weren’t.) There are also some 3rd trimester abortions that are due to “precise situations” associated with particular “social” conditions. (In other words, not all 3rd trimester abortions in Canada are due to medical issues).

Jumping ahead…

When couples receive a negative prenatal diagnostic, they must meet the OBGYN at least twice in the 48-72 hours after first being informed. This is to prevent a hasty decision. The couple must be exposed to four choices:

1) Pursue the pregnancy and evaluate the child’s condition at birth.
2) Organize palliative care at birth
3) Place the child up for adoption
4) Terminate the pregnancy.

The procedure for expelling the fetus.

This part is very important. Many people think that Partial Birth Abortion is a common way of killing third trimester fetuses. As far as I know, this is not the regular method used. This document describes the one I have come across the most: a prostaglandin abortion using feticide (i.e. killing the fetus with an injection).

I am putting the original French text so that there is no confusion.

Les interruptions de grossesse du troisième trimestre ont lieu à la salle d'accouchement. Elles sont pratiquées sous échographie par un gynéco-obstétricien. On tient compte de la douleur physique de la femme enceinte, même si elle n’est pas propre au troisième trimestre. On pratique une analgésie péridurale. Quant à la souffrance du foetus, la question est très controversée. Avant de réaliser l’IG, on administre au foetus des produits anesthésiques (Fentanyl), afin de soulager sa douleur. Cette pratique contribue à la sérénité du couple, mais aussi à celle de l’équipe soignante. Cependant, notons que tous n’administrent pas de produits anesthésiques.

La procédure d’expulsion du foetus consiste en une injection de chlorure de potassium (KCl) intra-cardiaque ou intra-ombilical provoquant le décès du foetus avant son expulsion. L’opération se déroule comme un accouchement normal, c’est-à-dire avec des contractions et une délivrance par les voies vaginales. Il y a toutefois naissance d’un enfant mort-né. La femme est ensuite conduite dans une unité où on lui offre des soins post-partum, axés sur le deuil.

Translation :

Third trimester abortions take place in a birthing room. They are performed with ultrasound by an OB\GYN. The pregnant woman’s pain is taken into account, even if she has not quite reached the third trimester (unsure of translation). An analgesic epidural is performed. In regards to the suffering of the fetus, this question is very controversial. Before starting the termination, the fetus is given an anesthetic (Fentanyl) to relieve him of pain. This practice contributes to the couple’s serenity, but also to that of the treatment team. However, note that not all professionals administer anesthetic.

The expulsion procedure consists of an intra-cardiac or intra-umbilical injection of potassium chloride (KCL) [i.e. injected in the heart or umbilical cord] which causes the death of the fetus before his expulsion. The operation continues as a normal birth, that is, with contractions and vaginal delivery. Nonetheless, there is the delivery of a child born dead. The woman is then directed to a unit where she is given post-partum care, focused on grieving.

The Discomfort Surrounding This Practice

The Committee observed that some decisions did not upset the professionals at all and there is consensus on them, while others are debated. For instance, grave or lethal pathologies do not pose any problem; pathologies such as: when the patient is non-viable, severe neurological pathologies; when the consequences are very difficult and almost certain; issues involving kidney where there is no chance of survival; some chromosomal issues and certain genetic conditions. However, there is no consensus on third trimester abortions for Down Syndrome and Spina bifida (which, I might add, are among the most frequent reasons for late-term abortions).

It is the uncertain diagnoses that create a dilemma. Some professionals opt for abortion; others prefer pursuing the pregnancy and evaluating the situation at birth.

There is a sentence that is important that I’m not sure I understand. It says:

Selon un point de vue, la pratique des IG du troisième trimestre favoriserait une attitude interventionniste, ce qui augmenterait les demandes pour les interruptions de grossesse à ce stade.

If I understood the sentence correctly, it says that third trimester abortions favour an « interventionist attitude », which increases the number requests for abortion.

In other words, the doctor has to intervene to tell people about the possibility of abortion, offer it to them, which plants the idea of abortion in the couples’ head, when they otherwise would not have had the idea in the first place.

That is my understanding of the sentence, but I’m not completely sure.

In that “interventionist vein”, some fear the banalization of abortion—making it routine and everyday. Others fear the spectre of eugenics.

Other professionals fear that the request for third trimester abortions is a reaction to the lack of services for handicapped children.

On the other hand, some fear that those reactions might limit access to abortion.

The document goes on to explore various ideas and attitudes about abortion and the fetus, according to various religions and the various historical periods.

The document relates some interesting information, which I did not know.

The Quebec Civil Code recognizes the fetus as a juridical person if he is born alive and viable. The document states that since aborted fetuses are never born alive, they never achieve any kind of juridical status.

The problem is that, of course, that’s not always true. It is possible for a third trimester fetus to survive a botched abortion and breathe.

The survival of a fetus from a botched abortion could raise possible legal issues of legal succession and transmission. It would have to relate to a very particular situation. But it’s not impossible.

The document goes on to say that the pace of prenatal testing has far outstripped our ability to treat the unborn child. It also cites, without context, a disturbing quotation from a bioethicist:

Rochefort38 mentionne que le diagnostic prénatal est maintenant considéré comme un « droit légitime » qui permet de donner naissance à un enfant normal. Il ajoute que l’ « … utilisation (de cette technique) est un devoir qui sous-tend une attitude responsable évitant de donner naissance à un enfant handicapé. »


Rochefort mentions that prenatal diagnostics is now considered a “legitimate right” that permits to give birth to a normal child. He adds that “the use (of this technique) is a duty that implies a responsible attitude of avoiding giving birth to a handicapped child.”

As this comes from a hospital, that is chilling. “Avoiding giving birth to a handicapped child” is a “responsible attitude”?

Margaret Sanger anyone?

Recommendations (The most relevant ones)

6.1 That third trimester medical abortion is acceptable when there is a strong possibility that the unborn child suffers from a recognized serious fetal anomaly that is known to be incurable at the time of diagnosis.

This recommendation expands the number of weeks that Ste. Justine performs abortion. Up until then, had a very limiting policy on third trimester abortion.

6.2 That medical and paramedical structures regarding third trimester abortions be put in place in order to adequately respond to the needs of the woman (or the couple).

6.3 That the diagnostic process and the announcement of the diagnosis take place with respect and humanity. (Except for the unborn child, of course).

6.4 The the woman’s (or the couple’s) decision be free, enlightened and supported throughout the process.

Here’s an interesting sub point:

6.4.10 qu’un soutien psychologique soit accessible aux intervenants, dans des situations particulièrement difficiles à vivre.

That psychological support be accessible to interveners, in situations that are difficult to experience.

6.5 Humanize the end of life, in the event of the woman (or the couple) choosing to proceed with an abortion.

Interesting sub-paragraph:

6.5.1 que le protocole des IG du troisième trimestre soit appliqué et que l’on s’assure d’éviter toute souffrance au foetus, advenant la décision de procéder à une interruption de grossesse ;

Translation :

That the protocol for third trimester abortions be applied and that it is assured that the fetus avoids all suffering., in the event to proceed with an abortion.

Don’t try to legislate that though. That’s crazy talk!

No word on whether the recommendations of this report were implemented.