Why Do Women Have Abortions After 20 Weeks, Anyway?

Sept. 26, 2013— -- Psychologist Dr. Julie Bindeman has always been pro-choice about abortion. But she remembers feeling relieved when she got married that she wouldn’t have to worry about making that decision personally. She was in a stable relationship and children were planned for her future.

At 29, she and her husband welcomed their first child, and a year and a half later found they were expecting again. That pregnancy ended in miscarriage, so they proceeded with cautious optimism when Bindeman became pregnant again. But things looked to be progressing well; they got through the first trimester just fine, and Bindeman began to tell clients about the pregnancy.

Then, a 20-week ultrasound and follow-up tests brought things to a screeching halt. Tests revealed enlarged brain ventricles and the possibility of anencephaly, which essentially translates to “no brain.” The best case scenario, doctors told the couple, was that the baby (a boy, the ultrasound had revealed) would have the mental capabilities of a two-month-old.

An option that had seemed a distant prospect was suddenly very much on the table. Bindeman could give birth, her doctors said, or terminate the pregnancy. If she chose to terminate, she would have to travel from her home in Maryland to New Jersey for the procedure, because no one in the area was trained to do it, or she could be induced near her home. She chose the latter and a gruelling 18-hour labor followed.

Chances of a repeat situation, they were told, came in around “one in a million.” The couple were soon pregnant again, this time with a girl. But tests around the 17-week mark raised some flags and the couple found themselves thrust into a battery of tests that again revealed enlarged brain ventricles and other abnormalities. This time, because she was within a 20-week window, she had her abortion in Washington, D.C.

Doctors said future pregnancies likely had a one in four chance of ending similarly, but they wouldn’t know until around 18 weeks at the earliest. Accepting the risk, the couple became pregnant again and had a healthy daughter in July 2011. A son followed in June 2013.

"This has nothing to do with politics," Bindeman said of her decision to have the two abortions. "This has to do with the choices that my husband and I needed to make."

But a slew of politicians, many of them Tea Party candidates swept into office during the 2010 election cycle, beg to differ.

As Elizabeth Nash, state issues manager for the Guttmacher Institute, which tracks abortion laws, told Fusion in July, this year is on track to see the second-highest number of abortion restrictions ever. There have been close to 50 restrictive laws introduced so far in states across the country, from North Dakota to Texas, Arizona to Pennsylvania.

Many of the proposals, advanced largely by Republican men, target so-called “late-term abortions.”

What exactly does that mean? According to the medical community, not much.

“Late term doesn’t mean anything in terms of how pregnant someone is,” said Dr. Anne Davis, M.D./M.P.H., the consulting medical director for Physicians for Reproductive Health, which works to improve access to abortion.

Doctors work in terms of weeks, Davis, who is also an associate professor of clinical obstetrics at Columbia University, said. A fetus is viable around 24 weeks, but many states have tried to restrict abortion to 20 weeks or before based on the ill-founded claim that a fetus can feel pain at that time. While the vast majority of abortions happen well before that time, there are some valid reasons a woman might require an abortion between 20-24 weeks, she said. There are just a few doctors who openly perform abortions after 24 weeks.

Davis performs around 75 abortions per year that fall within the 20-24 week time frame. There are medical abnormalities, particularly in the heart and brain, that only show up after 18-20 weeks, she said.

Bindeman would fall into that category, as do many of Davis’ own patients. A patient recently had a second pregnancy aborted when tests around the 20-week mark revealed a heart that was not developing normally, as well as other major organ malformations. Those tests can’t happen earlier because fetal structures aren’t developed enough until that time to really get a sense of what’s going on, she said.

Even if a woman has tests done around the 18-week mark, she’s likely to have follow-up appointments with other doctors. She’ll want to talk to her family and, if she chooses, will need to find someplace to have an abortion and schedule it.

The upshot is that many women end up outside the 20-week mark unavoidably and are left jumping through hoops at an already emotionally trying time.

“I feel like these are very paternalistic kinds of laws because the men who enact them and legislate them and try to pass them have never ever been in that situation and to have someone else tell me what is right for my family seems to be very arrogant,” Bindeman said, adding that she “would say that too even if the law said you have to abort.”

There are some other factors that lead women to have abortions. Maternal health, for example, can change after 20 weeks of pregnancy, Davis said. Conditions like diabetes and high blood pressure often worsen after that time and can pose severe risks to the mother’s health, as well as to the baby’s development.

Many states, even those with tight restrictions, include exceptions that allow abortions when the mother’s life is endangered. But there’s no easy way to define that, which can leave patients and doctors negotiating very tricky situations.

“There’s no area of medicine,” Davis said, “and in fact it would be malpractice, where you would say, ‘We have a treatment but we’re not giving it to you because we’ll wait to see if you get sicker.’ So, if an abortion would turn a situation around - say, if a woman had very bad high blood pressure - you don’t want to be in the position of watching patients get sicker. It’s not cut and dry and once patients are sick, we should be able to care for them.”

And most states don’t consider fetal viability when it comes to abortion laws, so women, like Danielle Deaver of Nebraska, can end up carrying a fetus they know will not survive. Births, both vaginal and cesarean, carry “much higher” risks than abortions, Davis said, because “needing an operation for an abortion is vanishingly rare.”

Social circumstances can also lead a woman to decide after 20 weeks of pregnancy that an abortion is necessary. One of her patients found out her spouse had cancer and the family didn’t feel they could cope with a new baby and care for a sick husband at the same time. Davis saw women during the recession who lost jobs and could not afford to have a child. She sees teens and other women, too, who either find out they are pregnant much later than normal or have been in denial.

“Abortions are very uncommon [between 20 and 24 weeks],” Davis said. “But I do see patients every week.”

And there’s no category to describe the women she sees, Davis said, because they are so diverse. They are not all irresponsible young women, as some critics would have people believe.

“I see women with lots of resources, poor women, young women, old women, people with IVF complications, other high risk pregnancies that wind up taking a turn,” she said. “That’s medicine; things are so individual.”

The truth is that abortions after the first trimester of pregnancy are very rare, but the women who do have them are very real. And politicians, Davis said, don’t always seem to remember that. They view it in the abstract and play on people’s emotions.

“Patients say ‘we never thought we would be in this situation, we couldn’t imagine it,’” she said. “No one wants this.”

The 20-week bans that have gained popularity among a particularly religious set of conservatives “would’ve restricted someone like us who didn’t get a diagnosis until 20 weeks and confirmation at 21,” Bindeman said. “There’s no way to know before 18 weeks and we’re lucky to live near the nation’s Capitol and have healthcare and amazing doctors, but not everyone lives here.”

She added that she’s concerned the more lawmakers try to craft abortion-related legislation, the fewer clinics will be able to perform it, which will limit competition and drive prices up.

“You’re not punishing the people who have means,” she said, “you’re punishing the people who don’t. It creates a very tiered kind of medical class system.”