Abortion After 20 Weeks

A few days ago, I received an email from one of the many pro-choice organizations I follow. The email was in panic mode:

“URGENT! Your signature needed! Our reproductive rights are being threatened again!”

Two days ago, Congress passed a bill banning elective abortion after 20 weeks gestation. “Elective,” meaning not due to conditions dangerous to the mother (such as preeclampsia or eclampsia), or fetal demise, or fetal malformations that are incompatible with life. Those are still possible. Just not, “I don’t want to have this baby.” I haven’t read the full text of the bill, so I don’t know what other exceptions there are. Stay tuned.

I took a deep breath and wrote a letter, but not the kind they wanted or were expecting.

You see, I have a lot of personal history surrounding both abortion and fetuses, and from where I stand, it’s not so simple. Truth be told, it’s never simple to curtail any life, no matter how tiny or how tenuous.

When I was a 16 year old virgin, in 1970, I was drugged, dragged into a dark basement, and raped so violently that after two reconstructive surgeries my nether parts are still not normal. I ran away, partially because the much older man who did the rapes was then sharing me with his friends and as a young person with Asperger Syndrome I didn’t know what to do, and partially because my mother’s abuse escalated around that time, probably due to my increased vulnerability. I fled from Massachusetts to California, where instead of peace and love I found more rape.

I missed a couple of periods. My breasts were swollen. I had no idea what was going on, since there was no such thing as sex education in the schools at that time, and my parents were phobic about anything having to do with sex. I went to a mobile street clinic and discovered I was pregnant.

Being California, there were choices. I could have the baby and keep it; I could have the baby and give it away; or I could have an abortion. I couldn’t fathom either of the first, so I settled upon the latter.

My pregnancy was past 11 weeks by the time I discovered it. California law required that pregnancies over 12 weeks be terminated in the hospital rather than the clinic because of the different technique necessary and the increased danger of perforation of the uterus. The soonest they could schedule me was in two weeks, at almost 14 weeks of pregnancy.

I’m glad they did it in the hospital, because they knocked me out. All I remember is the OB resident coming to see me afterward in tears, ranting at me about “people thinking they can use abortion as birth control.” I had no idea what he was talking about, or why he was so upset.

Fast forward to 1988.

I was a second year resident in Pediatrics at a big city hospital. My Neonatology rotation included participation on the Perinatal Ethics Committee, which deliberated on matters concerning difficult pregnancies and how to handle them.

There was a woman in her fifth month of pregnancy on the inpatient Obstetrics ward. She was 38 years old and had been pregnant already many times, and had miscarried every time. Her underlying problem was high blood pressure, which prevented proper blood flow to the placenta. She routinely miscarried between 18 and 24 weeks. At that time, and mostly until this day, for specific reasons, 24 weeks was considered the lower limit of fetal viability. Efforts to work around those limits are ongoing, but for the most part not practicable.

But she desperately wanted her baby. The perinatal team knew her well and liked her in spite of her challenges. They felt that if it were technically possible to save her baby, then we had a mandate to do all we could to deliver her a living child.

Now, this lady was no married, upper class, healthy white person. She was black, intellectually disabled, and chronically ill with severe hypertension due to lupus. She was unmarried, lived in a rough part of town, and had a criminal record for theft. In other words, a high-risk prospective parent under any circumstances, and especially for a very premature delivery. What was the prognosis, really, for her to safely and effectively parent a tiny preemie who would, if she survived, need intensive care in the hospital for months and intense home care for years afterward? Not so good. We debated the issue for hours and hours. The lady really desperately wanted her baby, but we were literally not certain we could deliver a viable baby for her, and certainly not a healthy one.

What should we do?

One thing in favor was stress. Normally we think of all kinds of stress as undesirable. We’re always thinking up new ways to combat stress in our lives. But stress is the premature baby’s friend. Stress in utero leads to increased stress hormone production by both mother and fetus, and this speeds the maturation of the fetal lungs. That was one good thing. After the lungs, the greatest challenges are the kidneys, and the skin. In utero, the placenta takes care of fetal waste, but undeveloped kidneys are something we have not learned to adequately deal with on the outside. Likewise, no need for skin inside, but here in the big world, without skin we quickly dehydrate and without its protective barrier, bacteria get in and wreak havoc.

These things don’t finish their development until the middle of the 23rd week. Our job was to keep this lady pregnant until the end of that week, if possible.

The plan was to do thrice-daily ultrasounds of the maternal-fetal circulation. Her problem had historically been that because of her hypertension, her placenta would become calcified, leading to a net reversal of blood flow so that instead of her blood going to the fetus, the blood flow became reversed, so the fetus became starved of oxygen and died. We put her on complete bed rest with high levels of supplemental oxygen, to keep the pregnancy going until that precious 24th week, at least.

In our cutting-edge neonatal ICU we boasted well over 90% survival at 26 weeks, unheard of at that time. That’s because our hospital pioneered the use of pig surfactant, a substance that, when blown into the stiff lungs of a tiny preemie, caused those lungs to become suddenly functional. It was nothing less than miraculous.

(Part of that miracle is that it was discovered by an Orthodox Jewish postdoctoral fellow, who would come into the hospital at all hours to blow a tube of pig lung secretions down a baby’s tube.)

This almost entirely eliminated the biggest barrier to survival of premature babies, the lungs, unmasking the next big challenges, which were and still remain, skin and kidneys. (We don’t have artificial substitutes for either kidneys or skin, but believe me, they’re working on it.) So we knew that if we could get this little girl past that 23rd week, between the stress and the surfactant we’d stand a pretty good chance for having her grow up.

The neonatal team was on call for the moment the blood flow in her placenta reversed. If she made it to 24 weeks, we’d deliver by Cesarian section and then, if she breathed spontaneously or with minimal intervention, we’d go all out. If she did not breathe, we would not intubate her. That was the compromise we worked out.

As it turns out, she never made it to 24 weeks. At 23 1/2, placental blood flow reversed. We had a quick conference and reconvened in the delivery room, where the fetus was removed by Cesarian section and handed off to the attending neonatologist, who happened to be me.

Squirming in the surgical towel they handed me was the tiniest human I have ever seen. I placed her on the scale: 325 grams, about a third of a pound. I’ve had burgers bigger than that! Her eyes were open, and she had all her fingers and toes. She was perfect.

As I laid her very carefully on the cold scale, a hole opened in her tiny face and a huge wail came out! She cried lustily, and I shrugged as I handed her to the NICU nurse.

“She wants to live,” I observed.

“Damn right she does,” said the nurse protectively, placing her in the warm incubator. “Let’s roll!” And they took her to the NICU, where she endured many challenges but never gave up.

I followed her until she was nearly 3 years old, then lost track. She didn’t have it easy. Her mother predictably dropped out of the picture, but her aunt took over and did a great job with her. She never had any of the really disastrous preemie problems (brain bleeds, oxygen toxicity, gut problems, sepsis.) We figured the stress she endured prenatally might have helped. Or maybe, as in the Jewish way of thinking, her soul really, really needed this particular vehicle in order to accomplish its mission.

No matter. After holding that little tiny life in my hand, watching her hang onto that life for all she was worth and actually grow up, there’s no way I’m going to say that a 20+ week fetus does not feel, or is not alive.