Explained by a doctor.....

What’s missing from the conversation about later abortions, explained by a doctor

Abortion opponents are accusing doctors of infanticide. Here’s the reality of abortion later in pregnancy, according to a doctor.

By Anna North

President Trump on Saturday yet again claimed that doctors in America are executing babies.

“The baby is born,” Trump said at a rally in Green Bay, Wisconsin. “The mother meets with the doctor. They take care of the baby. They wrap the baby beautifully, and then the doctor and the mother determine whether or not they will execute the baby.”

Trump’s inflammatory words are part of a larger movement. At an especially contentious time in the abortion debate, opponents of the procedure have focused their attention on abortions that happen late in pregnancy. In some cases, they’re implying that laws allowing later abortions make it legal to kill a baby after birth (they do not).

Such claims began to proliferate in January, after Virginia Gov. Ralph Northam made some confusing comments about an abortion bill in his state. Abortion opponents claimed his comments were an endorsement of infanticide. They argued that babies are sometimes born alive after failed abortions that happen late in pregnancy, and that they are then “left to die” or even executed by doctors.

“The governor stated that he would even allow a newborn baby to come out into the world,” Trump told a crowd in El Paso, Texas, in February, “and wrap the baby, and make the baby comfortable, and then talk to the mother and talk to the father and then execute the baby.”

Abortion rights advocates and abortion providers have responded to rhetoric like this by saying that the case of a baby born after a failed abortion is so rare as to be essentially unheard of, and that if that did happen, doctors would care for the baby like any other patient. But the debate continues, so I reached out to a doctor who provides abortions for an in-depth explanation of what abortions late in pregnancy actually look like, and how the picture painted by Trump and others compares to reality.

Dr. Kristyn Brandi is a New Jersey OB-GYN with fellowship training in family planning, and a board member of Physicians for Reproductive Health. As a doctor, she delivers babies and cares for pregnant women, and also performs abortions. She told me that because of today’s legal requirements for abortion procedures, it’s essentially impossible for a baby to be born alive after a failed abortion, and that equating late abortion with infanticide is insulting to patients, many of whom are grieving the end of a much-wanted pregnancy.

Trump and others describe “late-term abortion” (which, Brandi explains, is not a medically accurate term) as something that can happen at 40 weeks’ gestation, even when a woman is in labor.

In reality, as Brandi told Vox in February, “patients do not request abortion when they are in labor and doctors do not provide it.” More than 90 percent of abortions happen within the first trimester of pregnancy. But some patients do get abortions after that, in the second and third trimesters (about 1.4 percent of abortions happen at 21 weeks’ gestation or later, according to Planned Parenthood). Brandi explained to me what happens during those procedures, why patients seek them, and what the current political debate about them is missing. Our conversation, via phone and email, has been edited and condensed.

Anna North
Throughout the last few months, there’s been a lot of focus on abortions that happen later in pregnancy. Can you talk a little about why people seek such abortions?

Kristyn Brandi
Thank you for using the more appropriate terminology. A lot of the people I’ve been talking to about abortions that happen later in pregnancy use these weird terms like “late-term abortion.”

Anna North
Can you explain why the term “late-term abortion” is not accurate?

Kristyn Brandi
Usually, as medical professionals, we talk about abortion in relation to gestational age, but we don’t use terms like “late” because it doesn’t really apply. And when we talk about late-term pregnancy, we’re actually referring to pregnancies that are a week after their due date, so 41 weeks’ gestation, which is very different than what we’re talking about typically when people say late-term abortion. Which I think really reflects the fact that people that are having these conversations may not have that medical background, and so we’re not speaking the same language and it creates confusion for everyone involved.

Anna North
Given that, can you talk to me about the reasons that people seek the procedure later in pregnancy?

Kristyn Brandi
I should say that when we’re talking about these abortions later in pregnancy, this is about 1 percent of all abortion care. The majority of abortions happen in the first trimester. Patients that are seeking care later, often it’s related to their health, so either they themselves are diagnosed in pregnancy with some type of medical complication or their fetus was diagnosed with some type of genetic abnormality that makes their quality of life after they deliver really poor. And, unfortunately, we are typically unable to diagnose these things until the second or the third trimester, so it leaves patients to be having these conversations later in their pregnancy.

There’s also structural and socioeconomic reasons why people show up later in pregnancy. For example, I’m at a center where I’m the referral center for the state, and so patients that are seeking care elsewhere may get referred to me and I’m often hours away from where they initially sought care. So it takes a while for them to get up to see me, and that includes not just the time it takes to come up here but also making sure they have child care for the children they already have, getting transportation. There’s so many different types of barriers that are created for health care in general, but specifically abortion care.

Anna North
Can you give some examples of situations you’ve seen where a patient sought an abortion late in pregnancy?

Kristyn Brandi
In recent memory, I had a clinic day where several patients had come to the clinic for abortion later in pregnancy for very different reasons. A person in one room had a fetus with trisomy 13 [a chromosomal disorder that can result in severe intellectual and physical disability], which was not diagnosed until later in pregnancy. In the next room, I had a patient for whom I was the fourth doctor she had seen — she kept being referred to other doctors because of her complex medical history and had to save enough for a bus ride for each doctor she saw. The last patient had a history of a near-fatal event in her last pregnancy, and while she didn’t personally agree with abortion, she decided it was the best thing for her to prevent the risk of her own death in this pregnancy.

Anna North
Talk to me all bit more about the structural barriers you mentioned. Can you give some more examples?

Kristyn Brandi
As more and more abortion restrictions come up, it creates a lot of barriers for patients seeking care. For example, there are some laws that say you have to come [for counseling] prior to obtaining an abortion, and that just may not be feasible for a lot of people, particularly if you live three hours, four hours away in a different state from where you’re getting care. It just is not something that our patients can manage, and it’s not their fault.

There’s some new laws that cause clinics that are nearby to close because they just can’t meet these standards that are not medically necessary, but that states put on these clinics to restrict care.

Anna North
Would removing some of those barriers mean fewer abortions later in pregnancy?

Kristyn Brandi
I think so. Again, it’s not the majority of abortions, but there are many people that are having these barriers. It can actually change a lot of what abortion care looks like if just we improved access to patients being able to get care in a timely way.

Anna North
I think a clear picture of what happens during an abortion would be helpful to our readers in making sense of some of the debates right now. I know some abortions are performed with medication, and some are surgical — can you describe both types, and talk a little about how the procedure changes at different stages of pregnancy?

Kristyn Brandi
A patient can decide on a medication abortion up to 10 weeks, with two different pills, mifepristone and misoprostol. A surgical abortion is often a seven- to 10-minute in-office procedure with vacuum aspiration, administered by a licensed clinician who gently dilates the cervix just enough to protect the cervix, then empties the uterus.

If an abortion is performed at 20 weeks or later, a drug may be injected to stop the fetal heartbeat before the uterus is emptied. How we complete the procedure depends on the wishes of the patient, their own medical circumstances, and our medical judgement. Sometimes we use a combination of instruments and aspiration to empty the uterus, and other times we proceed with an induction of labor just as we would with a stillbirth.

Medically, every pregnancy is different, and every person’s health circumstances are unique. There isn’t a bright line, so we can’t say, “We always do this.” We provide the procedure that is best for each patient based on their decision and our medical judgment.

Anna North
What typically happens to fetal remains after an abortion? Does this vary depending on when in pregnancy the abortion occurs?

Kristyn Brandi
Medical facilities dispose of bodily tissue, including embryonic and fetal tissue, in a sanitary manner that minimizes exposure to pathogens and risk of infection. Fetal tissue is treated respectfully and handled in a way that protects the privacy of patients. In some instances, patients may request a different disposition of the embryonic or fetal tissue. Such requests are deeply personal and tend to vary based on a patient’s cultural or religious traditions.

Anna North
Let’s talk a little bit about what’s been in the news the last few months. I was watching the debate in the Senate over [Nebraska] Sen. [Ben] Sasse’s bill, and he said, “We know that some babies, especially late in gestation, survive attempted abortions. We know, too, that some of these babies are left to die.” That struck me because it didn’t jibe with what I’ve read and heard from providers, which is that it’s extremely rare, if not unheard of, for a baby to be born alive after a failed abortion attempt. What would be your response to Sasse’s claim?

Kristyn Brandi
I also have been hearing a lot of these types of stories, and it also is shocking me as someone that provides this care every day. I think they’re trying to use extreme language and sensationalization to make people uncomfortable with talking about care that is just part of medical care. I think there’s a lot of confusion about what happens within abortion later in pregnancy and the unique circumstances that involve each individual patient, so it’s really hard to understand a lot of the nuances around this conversation when you’re just having these two sides that are using talking points to argue with each other.

Anna North
What kinds of nuances do you feel like are being missed here?

Kristyn Brandi
I think some of it is just a misunderstanding about what abortion care looks like, and particularly equating it to infanticide, which is really insulting. It’s insulting for me as an abortion provider, but I can’t imagine how insulting it is for my patients or women that have experienced abortion and they’re hearing all these crazy stories. I can’t imagine how disheartening it is and how it further perpetuates the stigma around abortion. How could you talk about your own abortion when you hear all these things in the media?

Anna North
Just to make sure we drill down on some of the claims we’ve been hearing here, I’ve even seen an estimate on an anti-abortion website that more than 900 babies survive attempted abortions every year, extrapolating from a 2007 British study. Is this a thing that happens? Do infants survive abortions, and what would happen medically if that did occur?

Kristyn Brandi
[In] typical abortion care, this is something that can never happen, and part of it is actually because of politics. There was this [2003] partial-birth abortion ban, which restricted this from happening. If we did what these politicians are claiming we’re doing, we’re already breaking the law. No one is actually doing that. At least, I should say, no credible doctor or practitioner is doing anything anywhere even close to what they’re suggesting.

Anna North
Explain that a little bit more to me. What is being suggested that can’t happen under that law?

Kristyn Brandi
Under that law, something has to be done to the pregnancy to stop it from growing prior to the abortion happening, specifically to avoid the scenario where a potential pregnancy is delivered and could survive outside of the patient. We have to do something to the pregnancy in order to prevent this from happening, so it’s already off the table.

But I think a lot of the confusion is that people are conflating abortion care with comfort care. For example, there are some patients that are in a similar scenario where their pregnancy outcome, for whatever reason, either a fetal anomaly or something in their medical situation, did not result in a pregnancy that will survive for very long outside of them. And so some patients elect to undergo something similar to a labor induction, which allows them to deliver what they call their baby and be able to actually spend time with it and be able to offer it comfort care.

Again, thinking about the scenarios that I’ve seen, it’s really terribly heartbreaking scenarios where it’s a desired pregnancy that people want to spend last moments with before this baby passes. And to think of the patients that I’ve seen that have gone through that, where they just want to hold their baby one last time before it passes away, those are the scenarios that these politicians are suggesting that we are performing infanticide on.

It breaks my heart to hear conservative media and politicians using these terms and not holding the hand of patients that are going through this process.

Anna North
Talk to me a little bit about the emotional aspect of the procedure for patients who are ending up seeking this later in pregnancy, especially if these are patients who had a wanted pregnancy and there’s an abnormality.

Kristyn Brandi
I think it’s very emotional for many patients. Someone has been planning this pregnancy and been preparing and getting their nursery all set up and then, all of a sudden, is faced with this devastating news; it’s heartbreaking.

I think to compound that with all of the stigma around abortion — I’ve had many patients come to me and say they never thought they would be in this circumstance, that perhaps they didn’t agree initially with abortion care because they just didn’t see how it would affect them. Many of them are very happy and relieved to be able to have that care available to them when they needed it the most.

Anna North
I think those were all the specific questions I had. Is there anything else you want to say on any of this that we didn’t touch on?

Kristyn Brandi
I think the one thing that is getting a little bit overlooked in this conversation is about how particularly this affects a vulnerable population. Patients that are having abortions later in pregnancy may face additional barriers — [they may be] of lower socioeconomic status, minority patients, LGBT patients, undocumented patients, or immigrant patients. They’re facing a lot of the brunt of this and it’s further perpetuating disparities.

Anna North
They are facing the brunt of this because they’re more likely to face some of those barriers to care earlier in pregnancy?

Kristyn Brandi
Right. Or they may not be able to access prenatal care and they’ll get these diagnoses later in pregnancy, and so a lot of later abortion disproportionately affects vulnerable populations. So not only trying to decrease barriers to abortion care but also improving access to prenatal care, improving access to contraception, improving access to any health care or decreasing a lot of the barriers that are faced by vulnerable populations may actually be able to help people get access to the care they need.