Late Terminations of Pregnancy - an Obstetrician's Perspective
Ellwood, David, Australian Health Review
THE RECENTLY REIGNITED DEBATE on abortion has raised many questions, including the number performed, the age of the women and indications for the procedure. Those on the "pro-life" side of the highly polarised participants have also focused attention on "late abortions". There have been suggestions that there may be large numbers of late terminations of pregnancy being performed, in some cases close to full term, with no medical indication other than a woman's choice not to continue the pregnancy. Indeed, the phrase "partial-birth abortion" which is sometimes used by political activists on the pro-life side may lead the uninformed listener to conclude that this is something close to infanticide, being performed at a time when survival for the infant is a realistic possibility. What then is the real situation with late terminations in Australia?
The term "late termination" is understood by most obstetricians to mean one that is carried out at or above 20 weeks' gestation. This legal watershed, beyond which the fetus attains a legal identity, often triggers a change in the decisionmaking process when a request for termination is made. This depends on the practice and laws that apply in various jurisdictions.
Decision-making in Australian states
In Western Australia, an expert medical committee appointed by the health minister has the legislated power to decide on whether or not a late termination can be performed. All of these procedures take place in that states tertiary women's hospital and are done for reasons of severe fetal abnormality or serious maternal illness. In South Australia the law clearly permits termination up to, but not beyond, 28 weeks of gestation, and the decision is essentially one between a woman and her doctor. In practice though, the indications for later termination are the same as in Western Australia.
In both New South Wales and Victoria the law does not provide any guidance for practitioners about gestational age or indications for late termination. However, in both states the processes in the major public hospitals are similar in that some form of local ethics panel or "termination review committee" is used to examine the reasons why the request has been made and the indications for the procedure. In practice, late terminations in public hospitals are almost always for reasons of severe fetal abnormality or where the mother has a lifethreatening illness exacerbated by the pregnancy.
New South Wales Health has issued guidelines for hospitals about the nature of the local ethics panel and its composition. In Victoria, individual hospitals have chosen their own methods of managing the approval process. In the Australian Capital Territory, where abortion has been specifically excluded from the Crimes Act, the sole tertiary hospital carries out a small number of late terminations using a local ethics committee process which mirrors (and in fact predated) the NSW Health recommendations. In Queensland and Tasmania, access to later terminations within the public hospital system is very limited, and the procedure is generally not carried out above 22 weeks' gestation.
The methods used for late termination vary, depending on the indication (particularly the nature of the fetal abnormality), the gestation and the preferences of the individual practitioner and patient. The most commonly used method is induction of labour using prostaglandins. A surgical procedure such as dilatation and evacuation, although possible, is less likely to be used at gestations beyond 20 weeks due to technical difficulties caused by fetal size and a higher rale of complications. Very infrequently, the method of choice may be either hysterotomy or caesarean section, if there are valid obstetric reasons for choosing this approach. In many cases, the birth of an intact fetus is preferable so that comprehensive post-mortem pathology can help to confirm the antenatal diagnosis. …