Intact dilation and extraction (D&X, IDX, or intact D&E) is a surgical procedure that terminates and removes an intact fetus from the uterus. The procedure is used both after miscarriages and for abortions in the second and third trimesters of pregnancy. When used to perform an abortion, an intact D&E can occur after feticide or on a live fetus.

In the United States, where federal law describes an intact D&E on a live fetus as a partial-birth abortion, the procedure is uncommon. The 2003 federal Partial-Birth Abortion Ban Act, which was upheld by the Supreme Court of the United States in the case of Gonzales v. Carhart, outlaws an intact D&E of a fetus with a heartbeat under most, though not all, circumstances.

Indications

As with non-intact D&E or labor induction in the second trimester, the purpose of D&E is to end a pregnancy by removing the fetus and placenta. Patients who have a fetus diagnosed with severe congenital anomalies may prefer an intact procedure to allow for viewing of the remains, grieving, and achieving closure. In cases where an autopsy has been requested, an intact procedure allows for a more complete examination of the body.

An intact D&E is also used in abortions to minimize the passage of instruments into the uterus, reducing the risk of trauma. It also reduces the risk of cervical lacerations that may be caused by the removal of bony parts from the uterus and the risk of retention of fetal parts in the uterus such as brain matter and tissue. In cases where the woman is Rh-negative, Rho(D) immunoglobulin (RhoGam) is administered to prevent the risk of developing erythroblastosis fetalis (hemolytic disease of the newborn) in subsequent pregnancies.

Removal of fetus and placenta

During the surgery, the fetus is removed from the uterus in the breech position. If the fetal presentation is not breech, forceps or manual manipulation can be used to turn it to a breech presentation while in the uterus (internal version). There is no difference in postoperative blood loss or major complications when compared to non-intact D&E. There is no difference in risk of subsequent preterm delivery. The term is not recognized as a medical term by the American Medical Association nor the American College of Obstetricians and Gynecologists. This term was first suggested in 1995 by Congressman Charles T. Canady, while developing the original proposed Partial-Birth Abortion Ban.<!--

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--> According to Keri Folmar, the lawyer responsible for the bill's language, the term was developed in early 1995 in a meeting among herself, Charles T. Canady, and National Right to Life Committee lobbyist Douglas Johnson.<!--

--> Canady could not find this particular abortion practice named in any medical textbook, and therefore he and his aides named it. "Partial-birth abortion" was first used in the media on June 4, 1995, in a Washington Times article covering the bill.<!--

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In the U.S., a federal statute defines "partial-birth abortion" as any abortion in which the life of the fetus is terminated after having been extracted from the mother's body to a point "past the navel [of the fetus]" or "in the case of head-first presentation, the entire fetal head is outside the body of the mother" at the time the life is terminated. The U.S. Supreme Court has held that the terms "partial-birth abortion" and "intact dilation and extraction" are basically synonymous. However, there are cases where these overlapping terms do not coincide. For example, the intact D&E procedure may be used to remove a deceased fetus (e.g., due to a miscarriage or feticide) that is developed enough to require dilation of the cervix for its extraction. Removing a dead fetus does not meet the federal legal definition of "partial-birth abortion," which specifies that partial live delivery must precede "the overt act, other than completion of delivery, that kills the partially delivered, living fetus."

In addition to the federal ban, there have also been a number of state partial-birth abortion bans. There, courts have found that state legislation (rather than federal legislation) intended to ban "partial-birth abortions" could be interpreted to apply to some non-intact dilation and evacuation (D&E) procedures. Non-intact D&E, though performed at similar gestational ages, is a fundamentally different procedure.

Controversy

Some people believe the D&E procedure illustrates that abortion, and especially late-term abortion, is the taking of a human life and therefore ought to be illegal. People who believe this consider the procedure to be infanticide, a position that many in the anti-abortion movement extend to cover all abortions. Some advocates, both for and against abortion rights, see the intact D&E issue as a central battleground in the wider abortion debate, attempting to set a legal precedent so as to either gradually reduce or gradually increase access to all abortion methods.

Dr. Martin Haskell has called the intact D&E procedure "a quick, surgical outpatient method" for late second-trimester and early third-trimester abortions.<!--

--> The Partial-Birth Abortion Ban Act of 2003 describes it as "a gruesome and inhumane procedure that is never medically necessary."<!--

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According to a BBC report about the U.S. Supreme Court's decision in Gonzales v. Carhart, "government lawyers and others who favour the ban, have said there are alternative and more widely used procedures that are still legal - which involves dismembering the fetus in the uterus." An article in Harper's magazine stated that, "Defending the Partial-Birth Abortion Ban... requires arguing to judges that pulling a fetus from a woman's body in dismembered pieces is legal, medically acceptable, and safe; but that pulling a fetus out intact, so that if the woman wishes the fetus can be wrapped in a blanket and handed to her, is appropriately punishable by a fine, or up to two years' imprisonment, or both." The U.S. Supreme Court has stated that intact D&E remains legal as long as there is first a feticidal injection while the fetus is still completely inside of the mother's body.

Some prominent opponents of abortion rights quickly defended the accuracy of Fitzsimmons's statements, whilst others condemned Fitzsimmons as self-serving.

In support of the Partial-Birth Abortion Ban Act, a nurse who witnessed three intact D&E procedures found them deeply disturbing, and described one performed on a 26½-week fetus with Down syndrome in testimony before a Judiciary subcommittee of the U.S. House of Representatives.

A journalist observed three intact and two non-intact D&E procedures involving fetuses ranging from 19 to 23 weeks. She "watched for any signs of fetal distress, but ... [she] could see no response, no reflexive spasm, nothing. Whether this was a result of the anesthesia or an undeveloped fetal system for pain sensitivity, one thing was clear: There was no discernible response by the fetus."

Abortion provider Warren Hern asserted in 2003, "No peer-reviewed articles or case reports have ever been published describing anything such as 'partial-birth' abortion, 'Intact D&E' (for 'dilation and extraction'), or any of its synonyms." Therefore, Hern expressed uncertainty about what all of these terms mean. The U.S. Supreme Court held in Gonzales v. Carhart that these terms of the federal statute are not vague because the statute specifically detailed the procedure being banned: it specified anatomical landmarks past which the fetus must not be delivered, and criminalized such a procedure only if an "overt" fatal act is performed on the fetus after "partial delivery." Justice Kennedy wrote for the majority and was joined by Justices Thomas, Scalia, Alito, and Chief Justice Roberts. A dissenting opinion was written by Justice Ginsburg and joined by Justices Stevens, Souter and Breyer.

State law

Many states have bans on late-term abortions which apply to intact D&E if it is performed after fetal viability.

Many states have also passed bans specifically on intact D&E. 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 in June 2000, thus resolving the legal challenges to similar state bans nationwide.

Since the Stenberg v. Carhart decision, Virginia, Michigan, and Utah have adopted legislation very similar to the Nebraska law overturned as unconstitutional. The Michigan law was similarly struck down for broadness and failure to provide a health exemption. Utah's law remains on the books, pending trial, but is unenforceable under a court-ordered preliminary injunction. Virginia's Law was initially ruled invalid, but was reversed and remanded to the District Court in the wake of the Gonzales v. Carhart decision, where it was upheld as constitutional. This is despite the fact the Virginia law criminalizes abortions for accidental or intentional intact D&E.

In 2000, Ohio introduced another "partial-birth abortion" ban. The law differed from previous attempts at the ban in that it specifically excluded D&amp;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."

In 2003, the Michigan Senate introduced Senate Bill No. 395, which would have changed the definition of birth and therefore effectively ban intact D&E. The definition of birth as defined in the bill was that once any part of the body had passed beyond the introitus, it is considered a birth. The bill included an exemption for the mother's health. The bill was passed by both the Senate and House of Representatives but was vetoed by governor Jennifer Granholm.

Since the passage of the Partial-Birth Abortion Ban Act in the United States and similar state laws, providers of later abortions typically induce and document fetal death before beginning any later abortion procedure. Since the bans only apply to abortions of living fetuses, this protects the abortion providers from prosecution. The most common method of inducing fetal demise is to inject digoxin intrafetally or potassium chloride intrathoracically.

In other countries

Questioned about the policy of the UK government on the issue in Parliament, Baroness Andrews stated that:

<blockquote>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.</blockquote>

References

  • Appeals court upholds Ohio "partial-birth abortion" law (AMANews article) : 19 January 2004.
  • Appeals Court decision in Haskell v. Taft, upholding Ohio PBA Ban : (decided 17 December 2003) Includes description of the procedure, Decision of the Court, and Dissenting opinion
  • Partial Birth Abortion Ban Act of 2003, signed by President Bush in March, 2003
  • Ohio law banning "partial birth feticide" : enacted 18 August 2000.
  • Stenberg v. Carhart Decision voiding Nebraska's PBA ban, circa 2000
  • HR 1833, vetoed by President Clinton in 1996
  • Congressional Testimony of Brenda Pratt Shafer, RN, March 21, 1996

Commentary

  • Ban Wagons – Reason Magazine article about the naming of "partial birth abortion" (supporting legality of the procedure)
  • About.com's Pros & Cons of Partial Birth Abortion (neutral about the legality of the procedure)
  • The Myth of Partial Birth Abortion, by Don Sloan, MD (supporting the legality of the procedure)
  • Partial-Birth Abortion – A Chink In The Pro-Abortion Armor (opposing the legality of the procedure)
  • The "Partial-Birth" Myth – No, it's not a birth (supporting the legality of the procedure)
  • Gina Gonzales as told to Barry Yeoman, "I Had An Abortion When I Was Six Months Pregnant," Glamour (supporting the legality of the procedure)

Other

  • Martin Haskell's 1992 monograph: Dilation and Extraction for Late Second Trimester Abortion , which called the procedure "Dilation and Extraction"
  • (aka Partial Birth Abortion) – All sides
  • Presbyterians pro-life: A Pediatrician Looks at Babies Late in Pregnancy and Late Term Abortion
  • A doctor's right to choose – Salon article