Intact dilation and extraction

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Intact dilation and extraction (IDX or Intact D&X), is a surgical abortion procedure wherein an intact fetus is removed from the womb via the cervix. The procedure may also be used to remove a deceased fetus, resulting from a miscarriage, that is developed enough to require dilation of the cervix for extraction. As an abortion procedure, its methodology – removing the fetus from the womb fully intact – has made it highly controversial. Though the procedure has an extremely low rate of usage Guttmacher.org [Abortion Incidence and Services in the United States in 2000] it has developed into a focal point of protest in the greater context of the abortion debate.

Partial-birth abortion (PBA) is a non-medical term used to refer to some late-term abortion procedures. [D & X/PBA Procedures: Introduction]. religioustolerance.org. Accessed April 14, 2006.
[Statement on So-Called "Partial Birth Abortion" Law]. The American College of Obstetricians and Gynecologists. Accessed April 17, 2006.
[Unconstitutional "Partial-Birth" Abortion Ban]. Religious Coalition for Reproductive Choice. Accessed April 14, 2006. While the term partial-birth abortion mainly refers to the Intact dilation and extraction procedure, courts have found that legislation intended to ban so-called partial-birth abortions could be interpreted to apply to some dilation and evacuation (D&E) procedures.[Abortion Bans: Myths and Facts]. American Civil Liberties Union. Accessed April 14, 2006.
[Stenberg v. Carhart, 530 U.S. 914 (2000)] Though sometimes performed during the same developmental stage wherein most IDX procedures are done, D&E is a separate procedure.

Contents

1 Terminology
2 Intact D&X Surgery
3 Circumstances in which the procedure is performed
4 Controversy
5 Legal and political situation in the United States

5.1 Federal law
5.2 State law

6 Legal and political situation in the United Kingdom
7 References
8 See also
9 External links

9.1 Legislation, Testimony, and Court Decisions
9.2 Commentary
9.3 Other

Terminology

The term "dilation and extraction", or "D&X", was coined by Cincinnati physician W. Martin Haskell, MD in a monograph that was distributed by the National Abortion Federation in September of 1992.Haskell, Martin. [Dilation and Extraction for Late Second Trimester Abortion]. Presented at the National Abortion Federation Risk Management Seminar, September 13, 1992. Haskell's term was a variation on "intact dilation and evacuation (intact D&E)", the term preferred by Dr. James McMahon, who developing the procedure in 1983 as an alternative to dilation and evacuation or D&E.[Owner of Bombed Atlanta Nightclub is Sister of Abortion Doctor]. Feminist Daily News Wire, February 26, 1997. The American College of Obstetricians and Gynecologists would later settle on a hybrid of the two terms, "intact D&X". "Intrauterine cranial decompression" is another medical term sometimes used in reference to the procedure.

The term "partial-birth abortion" was coined in 1995 by pro-life congressman Charles Canady (R-Fla)Alex Gordon. ["The Partial-Birth Abortion Ban Act of 2003"]. Harvard Journal on Legislation. Volume 41, Number 2, Summer 2004. (see footnote 15) and is primarily used in political discourse — chiefly regarding the legality of abortion in the United States. The term's first use is arguably from the original proposed Partial-Birth Abortion Ban, which circulated in discussion through the first half of 1995 and was formally introduced by the congressman on 14 June 1995.H.R.1833. [To amend title 18, United States Code, to ban partial-birth abortions]. Keri Folmar, the lawyer responsible for the bill's language, says the term developed in early 1995 in a meeting between her, Charles T. Canady; and National Right to Life Committee lobbyist Douglas Johnson.Gorney, Cynthia. [Gambling With Abortion]. Harper Magazine, November 2004. According to a Lexis Nexis search, the term's first use in the media came on 4 June 1995 in a Washington Times article covering the bill and other criticisms of the procedure.[FOX News toes GOP line, using the term "partial birth abortion."] Media Matters For America, Mon Dec 13, 2004.

There is debate over the term "partial-birth abortion". Those who support the term's use, typically supporters of legislation to limit or completely ban the IDX procedure, say it is an accurate and easily understood description of the procedure. Those who oppose the term consider it a political term used to frame the argument in a way which is favorable to those who seek greater legal restrictions, or a total ban, on this, certain, or all abortion procedures. Opponents of a ban on the procedure have also argued that the definition of such a ban is so vague that the law would have a chilling effect on physicians performing any abortion or other gynecological procedures such as dilation and curettage for various conditions of the uterus unrelated to termination. Doctors "have been successfully sued for failure to refer patients for late-term abortions in cases of fetal abnormalities."Trupin, Suzanne R. [Abortion http://www.emedicine.com/MED/topic5.htm] emedicine.com. Accessed April 25, 2006.

Another non-medical, more graphic term, brain suction abortion, was previously used in an Ohio bill that sought to ban the procedure. It is also a politically motivated term coined by opponents of the procedure.

Intact D&X Surgery

Preliminary procedures are performed over a period of 2-3 days, to gradually dilate the cervix using laminaria tents, sticks of seaweed which absorb fluid and swell. Sometimes hormones such as pitocin are used to induce the process of labor. Once the cervix is sufficiently dilated, the doctor uses an ultrasound and forceps to grasp the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is referred to by some people as the 'partial birth' of the fetus. The doctor subsequently extracts the rest of the fetus, usually without the aid of forceps, leaving only the head still inside the birth canal. An incision is made at the base of the skull and a suction catheter is inserted into the cut. The brain tissue is removed which causes the skull to collapse, allowing the fetus to pass more easily through the birth canal. The placenta is removed and the uterine wall is vacuum aspirated using a suction curette.["Surgical Abortion Procedures"] American Pregnancy Association. Accessed April 14, 2006.
Haskell, Martin. "[Dilation and Extraction for Late Second Trimester Abortion.]" Presented at the National Abortion Federation Risk Management Seminar, September 13, 1992

Circumstances in which the procedure is performed

IDX, along with dilation and evacuation (D&E), early induction of labor, and rare procedures such as saline abortions, are only used in the late stages of pregnancy. Late-term abortions are uncommon, with abortions at 21 weeks or later accounting for only 1.4% of all abortions in the USA.[Abortion Surveillance --- United States, 2002] CDC's National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Accessed April 14, 2006. Intact D&X procedures are used in approximately 15% of late-term abortion cases. This calculates to between 2,500 and 3,000 per year, using data from the Alan Guttmacher Institute for the year 2000. They are typically performed between the twentieth and twenty-fourth week of gestation.[Abortion Incidence and Services in the United States, 1995-1996]. Accessed April 17, 2006.

Women choose to have late-term abortions for a variety of reasons, such as not knowing they were pregnant earlier in the pregnancy and diagnosis of a fetal abnormality late in the pregnancy. Once the decision to have a late-term abortion has been made, a woman or doctor may choose IDX over other available late-term abortion procedures because:

The procedure results in an intact body the parents may grieve over.
The woman does not have to experience labor.
The woman does not have to undergo abdominal surgery.
Sharp instruments are inserted into the uterus fewer times than in a D&E abortion.
The fetus may have hydrocephalus, where the head may expand to a radius of up to 250% of a normal skull at birth, making it impossible for it to pass through the cervix. If live birth is desired, the physician may drain the excess fluid in utero using a syringe, or a caesarian section with a larger than usual incision can be used. If abortion is desired, D&X may be the simplest procedure.

Reasons a woman or physician may not choose IDX, opting instead for another abortion procedure, include:

IDX requires a larger dilation of the cervix than D&E.
Podalic version (turning the fetus into a breech position) can be dangerous to the woman.
The incision in the fetal skull is made blind; the physician may miss and injure the woman's cervix.

Controversy

Partial-birth abortion is particularly a target of pro-life advocates because they believe the procedure most clearly illustrates their contention that abortion, and especially late-term abortion, is immoral. Critics consider the procedure tantamount to infanticide,Koukl, Gregory. [Partial-Birth Abortion Is Not About Abortion]. Stand to Reason. Accessed April 25, 2006.
White, Deborah. [Pros & Cons of Partial Birth Abortions] About.com. Accessed April 25, 2006. or murder, a position which many in the pro-life lobby extend to cover all terminations.[The Official Point of View of the Romanian Orthodox Church on Abortion (summery)]. The Romanian Patriarchate. Accessed Apriol 25, 2006.
Achacoso, Jaime B. [A Sin and a Crime] Catholic.com. Accessed April 25, 2006.
Gonzalez, Ramon. [Pro-life teens challenged] Western Catholic Reporter. October 23, 2000. Accessed April 25, 2006. Many advocates, both pro-choice and pro-life, see the PBA issue as a central battleground in the wider abortion debate, representing an attempt to set a legal precedent so as to gradually erode reproductive rights.[Slippery Slope: Democratic Wavering in the Battle for Reproductive Rights]. PERRspectives.com. February 25, 2004. Accessed April 25, 2006.
[Strategic Initiatives] The Rockridge Institute. Accessed April 25, 2006.

The IDX procedure itself is also controversial. Dr. Martin Haskell, who made the National Abortion Federation presentation, called it "a quick, surgical outpatient method" for late second-trimester and early third-trimester terminations. The Partial-Birth Abortion Ban Act of 2003 describes it as "a gruesome and inhumane procedure that is never medically necessary,"108th Congress, 1st Session, S.3. [Partial Birth Abortion Ban Act of 2003]. although pro-choice groups argue that it is more humane than D&E, the most common second-trimester abortion method, and some doctors question the assertion that it is never medically necessary.

Legal and political situation in the United States

Federal law

George W. Bush signing the Partial-Birth Abortion Ban Act of 2003, surrounded by members of Congress.

Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. Congress passed two such measures by wide margins during Bill Clinton's presidency, but Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful.

A major part of the legal battle over banning the procedure relates to health exceptions, which would permit the procedure in special circumstances. The 1973 Supreme Court decision Roe v. Wade, which declared many state-level abortion restrictions unconstitutional, allowed states to impose certain restrictions on second- and third-trimester abortions. The companion ruling, Doe v. Bolton, required that states' restrictions on abortions must provide an exception for the health of the woman, and defined health to include mental as well as physical health, though in his concurring opinion Chief Justice Burger wrote, "plainly, the Court today rejects any claim that the Constitution requires abortions on demand". In practice, the Supreme Court has found most attempts to legislate restrictions on abortion to be in violation of Roe v. Wade.

In 2003, however, opponents of the procedure succeeded in getting the Partial-Birth Abortion Ban Act (HR 760, S 3) signed into law; the House passed it on October 2 with a vote of 281-142, the Senate passed it on October 21 with a vote of 64-34, and President George W. Bush signed it into law on November 5.

The Act includes an exception for the life of the woman, but explicitly not for non-life-threatening health issues; opponents believe that this exception is too narrow and have mounted numerous legal challenges. Beginning in early 2004, the Planned Parenthood Federation of America, the National Abortion Federation, and abortion doctors in Nebraska challenged the ban in United States District Courts in San Francisco, New York, and Lincoln, Nebraska, respectively. All three District Courts ruled the ban unconstitutional that same year, and their respective appellate courts (Ninth, Second, and Eighth) affirmed these rulings on appeal. In upholding the Nebraska court's ruling in 2005, the Eighth Circuit states that the law is facially unconstitutional, meaning the ban is unconstitutional in all circumstances. This decision awaits further appeal, as the U.S. Department of Justice has requested the Supreme Court to review the lower court's decision. That request was granted on February 21, 2006. The law has yet to be successfully enforced as of April 2006.

State law

Many states have bans on late-term abortions which apply to the IDX procedure if it is performed after viability.

Many states have also passed bans specifically on the IDX procedure. The first was Ohio, which in 1995 enacted a law that referred to the procedure as dilation and extraction. In 1997, the United States Court of Appeals for the Sixth Circuit found the law unconstitutional on the grounds that it placed a substantial and unconstitutional obstacle in the path of women seeking pre-viability abortions in the second trimester.

Between 1995 and 2000, 28 more states passed Partial-Birth Abortion bans, all similar to the proposed federal bans and all lacking an exemption for the health of the woman. Many of these state laws faced legal challenges, with Nebraska's the first to reach decision in Stenberg v. Carhart. The Federal District Court held Nebraska's statute unconstitutional on two counts. One being the bill's language was too broad, potentially rendering a range of abortion procedures illegal, and thus, creating an undue burden on a woman's ability to choose. The other count was the bill failed to provide a necessary exception for the health of the woman. The decision was appealed to and affirmed by both the Eighth Circuit and the Supreme Court on June 2000, thus resolving the legal challenges to similar state bans nationwide.

Since the Stenberg v. Carhart decision, Virginia, Michigan, and Utah have introduced laws that remain virtually identical to the unconstitutional Nebraska law. The Virginia and Michigan laws were similarly struck down due to broadness and the failure to provide a health exemption, Utah's law remains pending trial, though is unenforceable due to a court-issued preliminary injunction.

In 2000 Ohio introduced another partial-birth abortion ban. The law differed from previous attempts at the ban in that it specifically excluded D&E procedures, while also providing a narrow health exception. This law was upheld on appeal to the Sixth Circuit in 2003 on the grounds that "it permitted the partial birth procedure when necessary to prevent significant health risks."

Legal and political situation in the United Kingdom

Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologists' (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."

References

External links

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