The Science Behind Third-Trimester Abortions

SOPHIE BUSHWICK: This is Science Friday. I’m Sophie Bushwick.

The November election is a little over a week away, and in many states early voting is already happening. As we continue our coverage of how science is showing up on the ballot, we’ll focus on one of the top issues among voters. Since the overturn of Roe v. Wade, many states have curtailed access to abortion. In total, 13 states have laws that have banned abortion.

In particular, there’s been a focus on abortions in the third-trimester of pregnancy. Some of the rhetoric is inflammatory and false. But even among some pro-choice politicians, there’s a tendency to deflect attention away from these procedures later in pregnancy. Though third-trimester abortions are rare– they make up only about 1% of abortions in the United States– they are often the most stigmatized. They are only legal in a small number of states, and only a fraction of providers perform them. So what’s the real science behind this issue?

Joining me now to help us better understand third-trimester abortions are my guests, Dr. Katrina Kimport, professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, and Dr. Cara Heuser, a maternal and fetal medicine physician, who specializes in high-risk pregnancy and complex abortion care, based in Salt Lake City, Utah. Both of you, welcome to Science Friday.

KATRINA KIMPORT: Thank you for having us.

CARA HEUSER: Thanks for having us.

SOPHIE BUSHWICK: Dr. Heuser, I want to start with some basic terminology here. When we talk about third-trimester abortions, or, as some people call them, late-term abortions, what does that actually mean?

CARA HEUSER: I’m so glad you asked that question because late-term is not a medical term that we use for any type of abortion care. Pregnancy has been conventionally divided into three trimesters, somewhat arbitrarily. Sometimes people will also divide it into before 20 weeks or after 20 weeks. And people tend to think of abortions that happen either in the second or third trimester, or after 20 weeks, in a different way than we think of abortions that happen earlier in pregnancy. People have more feelings about that. They’re often more stigmatized. And so this is generally what is under the umbrella of quote unquote, late-term, although I do want to emphasize that that is not an accurate medical terminology. And we would say abortion after 20 weeks, or abortion at X gestational age, or abortion in the third trimester.

SOPHIE BUSHWICK: Dr. Kimport, in your research, you’ve interviewed many people who’ve had third-trimester abortions. Can you outline the reasons that people seek abortions in the third trimester?

KATRINA KIMPORT: I’ve talked to dozens of people who have had abortions after the 24th week of pregnancy, as well as people who’ve had abortions at all different gestations in pregnancy. And the pattern that I found is that people need an abortion later in pregnancy because of two main pathways. In the first pathway, they’ve received new information that wasn’t available earlier that made this pregnancy no longer one they wanted to continue. So that might include new information about the health of the fetus. It might include new information about their own health. It might include that they are pregnant. Some people don’t recognize their pregnancy until later in gestation.

The other pathway that I found for why people need an abortion later in pregnancy is that they wanted an abortion earlier in pregnancy, but they faced so many barriers to being able to get to abortion care that it wasn’t until after, say, the 24th week of pregnancy that they were actually able to present for care. And these barriers could include things like policy-related barriers. Something like an abortion ban is certainly a barrier to getting an abortion. It could also include things like stigmatization of abortion and sometimes things that aren’t related to policy at all, such as somebody who prevented them from traveling.

So these are the two main pathways that I’ve found for why somebody might need an abortion later in pregnancy. To be clear, these are not that hard to imagine once you put yourself in the shoes of somebody who might be having this experience.

SOPHIE BUSHWICK: And Dr. Heuser, your specialty is working with patients who have really complex and challenging decisions to make about their pregnancies. For example, if a patient finds out about a life-threatening fetal abnormality during the third trimester. Can you walk me through the options you present to your patients in this situation?

CARA HEUSER: Before I walk through that, I do want to say that while most of my patients are coming to me for abortion care because of an unexpected fetal finding, the reasons that Katrina laid out earlier for people seeking abortion care in the third trimester are all valid. People who need care need care regardless of their reason.

However, in my clinic, because I do high-risk pregnancy care, much of the time, we’re finding out about a severe fetal finding that wasn’t apparent earlier in pregnancy. When we find out about these devastating diagnoses, as you can imagine, this is life changing for a family. And so, first of all, I encourage everyone to A, take some time before they make any decisions, and B, I always offer everyone a second opinion.

So once we identify a fetal diagnosis that is life limiting or unlikely to be compatible with extrauterine survival, we offer our patients one of two options, really. The first one is to continue to carry to term, which is 37 to 42 weeks, have labor, have the baby. Sometimes a cesarean is necessary, especially in particular findings where the vaginal delivery is not possible. And I want to emphasize that we really support people who want to choose that path. And that is a very meaningful path that a lot of families choose and find to be very comforting and something that is very meaningful to them.

The other path that we offer patients is to end the pregnancy early. This is another way of saying having an abortion or early delivery. In those situations, there are many patients who do not feel that it is in their own best interest or the best interest of the pregnancy to continue to carry to term. And those patients may elect to end the pregnancy early. There’s a number of ways of doing that, and I walk them through those options, which I’m happy to talk about as well.

SOPHIE BUSHWICK: Yes, could you walk us through the different options for procedures in that situation?

CARA HEUSER: The first way that is always an option is an induction of labor. This is very similar to induction of labor at term. Sometimes we use slightly different medications, but the process itself is very similar. You come into labor and delivery. You get some medications to begin contractions They experience labor over a number of hours. They have a vaginal delivery. And then, usually in these situations– not universally, but often– the family wishes to spend time with that baby. And it’s actually a really profound experience. And there are family members. There’s pictures. It can help the healing process for these families.

With this choice of induction of labor, there’s also the option of having an injection to stop the fetal heart prior to labor. Some families choose for that because they really are worried about any suffering that might occur, or they simply, for whatever reason, would prefer that there not be a chance that the baby emerges with a heartbeat.

The other way to end a pregnancy is a uterine evacuation. So from the patient’s standpoint, they have some type of sedation or even general anesthesia. It’s very similar to a dilation and curettage that you might have heard about in other settings. And it’s more of a procedure, where we use instruments to empty the uterus.

In those cases with the uterine evacuations, especially later in pregnancy, those are accompanied by a fetal injection that will stop the fetal heart prior to removing the pregnancy from the uterus.

SOPHIE BUSHWICK: And my next question is for Dr. Kimport. Abortion, in general, is stigmatized, but abortion later in pregnancy is even more so. Why do you think that is?

KATRINA KIMPORT: When we’re talking about abortions later in pregnancy, a lot of these discussions are taking place without people actually knowing anybody who’s had this experience. So even while we’re hearing a lot of discussion, maybe in political discourse, maybe around the kitchen table, it’s not been informed by people who’ve actually had this experience. And so to fill in for those spaces, there are a lot of unknowns. People have filled in a lot of myths.

And I think that particularly when we’re talking about abortion later in pregnancy, the fact that most of our conversation about abortion as a culture and for the last 50 years– maybe even longer– has really been focused on thinking about the fetus and hasn’t had a way of talking about the person who’s pregnant. And so when we are thinking really in centering the idea of the fetus, as the fetus has more developmental markers, it can become, especially for somebody who has no familiarity with abortion later in pregnancy, really hard to imagine what somebody who is pregnant must be thinking, how their decision making could be working, and why possibly third-trimester abortion could be the right choice for somebody. So a real response to that is to instead think about that person who is pregnant and recognize that we can trust them to make the best decision for them and their families.

SOPHIE BUSHWICK: Dr. Heuser, does this stage of fetal development impact how you understand the abortion care you’re providing?

CARA HEUSER: There is something that often feels different to us about abortion later in pregnancy. I think that it’s human nature to think of a pregnancy at 32 weeks in a different way than we might think of a pregnancy at eight weeks. So I don’t want to ignore that or minimize it. But when I come down to bedrock principles of, as Katrina said, who makes these decisions, as we’ve discussed, almost by definition, someone seeking abortion care in the third trimester finds themselves in a situation where something has gone quite wrong. In almost no case is that situation improved by the interference of the carceral state.

When I think about who needs to do that moral calculus and who needs to make the decision, and I think about the different stakeholders or the different players, and I think, should it be the government? Certainly not. Should it be the physician? Probably not that either, honestly. Should it be the person who’s most impacted by the decision to have or not have a child, to bring another life into this world, and who knows their own life and circumstances best? Yeah, that is the person best positioned to add the moral weight onto each side and decide what is the best decision for them.

And it is my role as their physician to honor their choices and their independent ability to make those moral calculations and to trust them when they say that having a third-trimester abortion is what they need to minimize suffering and is the right decision for them.

SOPHIE BUSHWICK: And have your views on this changed over time?

CARA HEUSER: Honestly, yes. And this is something that I struggle a little bit to talk about because I don’t want to send the message that there is something shameful or wrong about having a third-trimester abortion. But I admit that in the past I have felt discomfort with it, especially when I am the one actually providing the service. And so I’ve really had to sit with this and really come back to my first principles and my core bedrock values. And as I’ve done that and thought about it, and as I’ve interacted more and more with patients seeking this care and sat with them and heard their stories, and when there is a person across from me asking me to help them, it feels impossible not to. It feels like an abdication of my ethical responsibility as a physician not to help them.

SOPHIE BUSHWICK: Well, Dr. Kimport, you’ve devoted a lot of time and energy as well to speaking with people who have had third-trimester abortions. Why do you think it’s so important to focus on these lived experiences?

KATRINA KIMPORT: So when we look at political conversations about abortion, sometimes there’s this idea that there’s some sort of common ground between people who are supportive of abortion, abortion rights, abortion access, and people who are opposed to it, and that somehow in our idea of finding common ground, that’s been translated into this idea that we could have some fixed point in pregnancy, some gestational point, after which would be not OK, before which would be OK. I think once I started talking to people who’d had abortions later in pregnancy, I understood how nonsensical the idea that there’s a line in pregnancy after which abortion shouldn’t be available– how nonsensical that is to their lives.

People who are pregnant don’t experience pregnancy by these specific cut points. So there was a person I talked to, who received information that there was probably– or potentially– a fetal health issue. She was about 22 weeks gestation. She was told, we think there’s a 70% chance that your baby is going to be fine, but we can offer you an abortion right now because you are under the state’s gestational limit. And she said, you’ve got to be crazy to think that that’s what I would want to do. I’ve got a 70% chance that my baby is going to be healthy, and this baby is very wanted.

As the pregnancy progressed and they were able to do additional testing and scans, they discovered that, in fact, not only was her fetus in that 30% that was probably going to be unhealthy, her fetus had one of the most severe cases of the observed fetal health issue. At that point, her calculus changed. This wasn’t a pregnancy she wanted to continue. But at that point, the state had said, nope, sorry, you are beyond the limit that was our common sense agreement. As she said to me, who thought this was the right outcome of this policy?

And when we think about the fact that the people who are beyond these gestational cutoffs are often people who, as Cara pointed out so eloquently, are experiencing some of the most complicated, sometimes heart-wrenching, sometimes harrowing circumstances that have led them to this point, and those are the people that we, in the political consensus world, have said, sorry, you don’t get help– I think when we start from them, it shifts the way that we think about and talk about what it means to have a consensus, what it means to have a line, and what the impacts are for people who are among the most vulnerable in our society.

SOPHIE BUSHWICK: That’s about all the time we have. Thank you, Dr. Heuser and Dr. Kimport. Thank you both so much for taking the time to be on the show.

KATRINA KIMPORT: Thank you so much for having me.

CARA HEUSER: Sophie, thank you so much for having us and being willing to talk about this important topic.

SOPHIE BUSHWICK: Dr. Katrina Kimport is a professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco. And Dr. Cara Heuser is a maternal and fetal medicine physician, who specializes in high-risk pregnancy and complex abortion care, based in Salt Lake City, Utah.

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