Abortion can be medically necessary to save the life of a pregnant woman

In a video published by the organization Live Action, which opposes abortion, neonatologist Kendra Kolb claimed that abortion is never medically necessary. One of the reasons she cited is that the treatment of life-threatening conditions like an ectopic pregnancy isn’t considered an abortion; another reason she cited is that abortion is unnecessary because doctors can perform a preterm delivery if terminating a pregnancy is necessary to save the mother. The video was viewed more than 440,000 times on Facebook.

However, the claim is false and the video obscures the complexity of the risks associated with pregnancy and the medical care needed to mitigate these risks. This review aims to shed light on these subjects to help readers better understand this complexity and why an abortion can become medically necessary to save the life of a pregnant woman.

Kolb’s claim that “abortion is never medically necessary” is at odds with advice by medical experts. The American College of Obstetricians and Gynecologists and Physicians for Reproductive Health released a joint statement in 2019, which is unequivocal on this subject: “Without question, abortion can be medically necessary”.

In a comment to Health Feedback, Jonathan Lord, consultant gynaecologist and spokesperson for the Royal College of Obstetricians and Gynecologists, a professional organization in the United Kingdom analogous to the ACOG, said “It is very concerning to hear claims that a preterm delivery should be used as an alternative to an abortion” as “[d]elivering prematurely is not a safe alternative to an abortion”.

“Where a serious health issue occurs later on in a pregnancy that needs urgent delivery, usually it is possible to save the baby without endangering the mother’s health. These decisions are made as part of routine obstetric care jointly with the specialist team and the woman. It may involve inducing labour or delivery by caesarean,” he explained. [See below for the full comment by the RCOG.]

“Every effort would be made to save the baby where that is wanted, but sometimes this simply isn’t possible or feasible.”

In general, the lay and medical definition of an abortion is the intentional termination of a pregnancy.

• The American College of Obstetricians and Gynecologists: “Induced abortion ends a pregnancy with medication or a medical procedure”

• The Royal College of Obstetricians and Gynecologists: “[A] way of ending a pregnancy, either through using medicines (drugs) or through a surgical procedure”

• MedLine Plus, run by the U.S. National Library of Medicine: “A procedure to end a pregnancy”

• Cambridge Dictionary: “The intentional ending of a pregnancy”

And the Legal Information Institute at Cornell Law School, similar to the above institutions, defines abortion as “the intentional termination of a pregnancy”.

That said, it’s true that the treatment for an ectopic pregnancy isn’t considered to be the same as an induced abortion, as they don’t involve the same skill set and medication. And the fact-checking organization PolitiFact also reported that most of the medical experts they consulted don’t consider the treatment of an ectopic pregnancy as an abortion.

However, that is not how Kolb explained this distinction. Instead, she claimed that “the only intent of an abortion is to produce a dead baby”, therefore treatments for life-threatening conditions wouldn’t be considered an abortion. She cited how chemotherapy to treat a pregnant woman could lead to a miscarriage, but this wouldn’t be an abortion since “the purpose of the treatment is not to kill the child”.

While it is true that cancer treatment doesn’t equate to an abortion, this doesn’t mean that abortions are never medically necessary. An ectopic pregnancy and cancer are only two of the many potentially life-threatening complications that pregnant women can experience. Other types of life-threatening conditions—which don’t fall within the cases cited by Kolb, also exist—such as placenta previa and preeclampsia. Placenta previa occurs when the placenta partly or completely covers the opening of the uterus. Preeclampsia are disorders stemming from high blood pressure related to pregnancy, and in serious cases, can lead to seizures and coma.

By leaving out any mention of these cases, the video offers viewers a misleading, overly simplistic representation of the risks faced by pregnant women.

In 2019, Health Feedback interviewed several medical experts for an earlier review, which dealt with the same claim by Live Action founder Lila Rose.

Alexis Shub, a maternal fetal medicine subspecialist and associate professor at the the University of Melbourne, told Health Feedback that “bleeding from placenta previa or abruption, or with preterm ruptured membranes with infection” may necessitate an abortion to save the life of the mother when they occur before a fetus can survive outside the mother’s body.

Daniel Grossman, a professor of obstetrics and gynecology at University of California, San Francisco, told Health Feedback that “If the pregnant woman develops a life-threatening condition at a gestational age when the fetus is likely to survive, it is true that in most cases, obstetricians would proceed with expedited delivery”.

“But,” he cautioned, “if the pregnant woman develops a serious condition at 20 weeks, such as ruptured membranes with signs of infection or heavy bleeding from a placenta previa, it is critical to terminate the pregnancy quickly to save her life. There is no chance that the fetus can survive, and an abortion would be the fastest and safest way to terminate the pregnancy”. To date, the most premature baby to survive was born in 2020, at about 21 weeks of gestation.

Put simply, inducing labor is one way to terminate a pregnancy and potentially save both mother and child, if gestation has advanced far enough. But when induced labor is performed before viability, it is described as an induction abortion, even if the baby might live for a short time following birth. An induction abortion is normally performed in the second or third trimester. Since babies can be born alive, albeit briefly, through such an abortion, it places Kolb’s definition of an abortion as a procedure only intended “to produce a dead baby” in question.

None of these conditions were discussed or even mentioned in the Live Action video.

The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG), which opposes abortion, prefers to use another term, “previable separation”, to describe such procedures. But this term isn’t used in healthcare or in official documents; for example, both Michigan’s Health and Human Services and the Louisiana Department of Health describe this procedure as a labor induction abortion.

Finally, real-world cases of women who died because they weren’t able to obtain an abortion speak for themselves. One is the highly publicized case of Savita Halappanavar. After developing a miscarriage, physicians in Ireland refused to perform an abortion as fetal cardiac activity could still be detected; Halappanavar subsequently developed sepsis and died approximately a week after her request for an abortion was denied.

In Poland, a woman named Izabela died in 2021 from septic shock after physicians declined to terminate her pregnancy either by inducing labor or performing a C-section, on the grounds that fetal cardiac activity was still present. While laws in Poland permit abortion if the mother’s life is endangered, the lawyer representing Izabela’s family, Jolanta Budzowska, told The Guardian that “it is hard for the doctors to apply this in practice.”

“They do not know if they make the right decision when this real danger occurs. If they carry out an abortion too early and the prosecutors then decide that there was no danger to the mother, they can face up to three years in prison”, Budzowska said.

Lord also highlighted the same dilemma that physicians face if a pregnant woman requires medical care to terminate a pregnancy. “Problems arise when the law has a chilling effect on clinicians, so they have to defend themselves from potential prosecution rather than act in the interests of the woman. Widely reported cases, most recently from Malta, have shown that treatment is delayed until the woman’s health is in significant danger, and in Ireland and Poland this delay has tragically resulted in the death of both the women and their babies”.

Indeed, while some states in the U.S. have enacted laws restricting abortion, these have often included an exception if the pregnant woman experiences a medical emergency. But the wording of these laws is vague, giving rise to confusion over what is or isn’t legal and leading to delayed care, which have repercussions for women’s health. These considerations are critical for physicians, who could face harsh penalties including jail time if they performed an abortion that others later considered wasn’t medically necessary. 

A Perspective article by Lisa Harris, a professor of obstetrics and gynecology at the University of Michigan, in the New England Journal of Medicine, highlighted the numerous ways in which providing necessary medical care for the mother can become legally ambiguous^[​1].

“What does the risk of death have to be, and how imminent must it be? Might abortion be permissible in a patient with pulmonary hypertension, for whom we cite a 30-to-50% chance of dying with ongoing pregnancy? Or must it be 100%?”

In summary, the sweeping claim that “abortion is never medically necessary” is false. It can be argued that ectopic pregnancy isn’t treated with an abortion, and preterm delivery can indeed be an option to end a pregnancy as opposed to an abortion. However, neither of these arguments address the many other life-threatening conditions that pregnant women may face. 

Furthermore, preterm delivery is only an option if the gestational age of the fetus is advanced enough to allow the fetus to survive outside of the uterus. Ultimately, in cases when a pregnant woman develops a life-threatening condition that requires terminating the pregnancy and when the fetus is less than 20 weeks old, an abortion becomes medically necessary to save her life.

The Royal College of Obstetricians and Gynecologists:

It is very concerning to hear claims that a preterm delivery should be used as an alternative to an abortion. Medical and surgical abortions are safe procedures for which major complications are uncommon at any stage in pregnancy.

There are many reasons why a woman may need an abortion. It may be an unwanted pregnancy, or be dangerous for a woman to continue a pregnancy. In England and Wales only 1% of abortions take place at over 20 weeks, and all those over 24 weeks are where there are serious anomalies in the developing baby or the mother’s life is in danger. Clearly every effort would be made to save the baby where that is wanted, but sometimes this simply isn’t possible or feasible.  

Delivering prematurely is not a safe alternative to an abortion as a high proportion of babies born before 24 weeks do not survive, and those that do have high rates of significant long term health issues. Advancements in neonatal care mean that the survival rate of premature babies is increasing, however babies born extremely prematurely (born between 22 and 26 weeks) require protracted care from multidisciplinary teams, and are at risk of developing severe longer term problems. 

Abortion care is an essential part of sexual and reproductive healthcare and the decision to have an abortion should be entirely up to the individual.

The College also provided additional information and context on the above comment below:

Where a serious health issue occurs later on in a pregnancy that needs urgent delivery, usually it is possible to save the baby without endangering the mother’s health. These decisions are made as part of routine obstetric care jointly with the specialist team and the woman. It may involve inducing labour or delivery by caesarean.  

In England and Wales only 0.1% of all abortions were at 24 weeks and over, almost all of these would be due to severe fetal anomaly.  

Problems arise when the law has a chilling effect on clinicians, so they have to defend themselves from potential prosecution rather than act in the interests of the woman. Widely reported cases, most recently from Malta, have shown that treatment is delayed until the woman’s health is in significant danger, and in Ireland and Poland this delay has tragically resulted in the death of both the women and their babies.  

Some rare types of ectopic pregnancy can also be life-threatening. Whilst most ectopic pregnancies are in the tube and there is no viable fetus developing, and therefore treatment is not defined as an abortion, sometimes they can develop in scars in the womb, or in the wall of the womb, and remain alive for some time until they catastrophically rupture. If these are not treated before this happens, not only is the woman’s life put at serious risk, but she is also more likely to need a hysterectomy which could have been avoided with earlier treatment.

[This comment comes from the evaluation of a related claim]

There is no doubt that abortion is necessary to save the life of a woman when she is at a previable gestation, usually before 23 or 24 weeks, or has a very growth-restricted fetus at a slightly later gestation, for example with a 300-gram fetus at 24 or 25 weeks, and the mother has a life-threatening condition which can only be improved by delivery.

This can occur in the context of severe pre-eclampsia or eclampsia, with bleeding from placenta previa or abruption, or with preterm ruptured membranes with infection (chorioamnionitis). This was demonstrated very clearly in the widely reported case of Savita Halappanavar. Savita was a 31-year-old woman living in Ireland who developed infection after her waters broke at 17 weeks. Termination of pregnancy was refused by her treating doctors, in the interests of preserving the life of the fetus, and she died the next day.

[This comment comes from the evaluation of a similar claim; at the time of commenting, Prof. Grossman served on the board of directors of the NARAL Pro-Choice America Foundation]

If the pregnant woman develops a life-threatening condition at a gestational age when the fetus is likely to survive, it is true that in most cases, obstetricians would proceed with expedited delivery. But if the pregnant woman develops a serious condition at 20 weeks, such as ruptured membranes with signs of infection or heavy bleeding from a placenta previa, it is critical to terminate the pregnancy quickly to save her life. There is no chance that the fetus can survive, and an abortion would be the fastest and safest way to terminate the pregnancy.

UPDATE (10 July 2022):

This review was updated to include a comment by the Royal College of Obstetricians and Gynecologists. This further supports our verdict and did not change it.

REFERENCES

• 1 – Harris LH (2022) Navigating Loss of Abortion Services — A Large Academic Medical Center Prepares for the Overturn of Roe v. Wade. New England Journal of Medicine.