Abortion up to 24 weeks – A woman’s perspective
“Abortion” in simple terms means to end a pregnancy. Abortion brings with it a variety of medical, legal, social and ethical issues. A woman may terminate her pregnancy voluntarily by taking medication or having a medical procedure.
Medical termination of pregnancy is considered safe for the woman till the 20th week of pregnancy. Safe abortion also makes it legal for women to terminate their pregnancy for medical or social reasons up to 20 weeks from the time of conception.
Conception marks the onset of pregnancy, the state of carrying a developing embryo or the fetus within the female body for an optimal period of 42 weeks measured from the last date of the woman’s menstrual period (LMP).
An abortion can legally be performed by a medical practitioner on various grounds. When a woman gets her pregnancy terminated voluntarily, it is called induced abortion. Medical termination of pregnancy (MTP) is to be done with the consent only of the woman whose pregnancy is being terminated unless the woman is a minor or is mentally challenged.
This means that the medical practitioner need not seek an adult pregnant woman’s husband or family for consent on terminating her pregnancy. The MTP act allows the woman to decide autonomously and this has helped women stigmatize abortion to a certain extent.
The Medical Termination of Pregnancy Act, 1971, is responsible for the legalization of abortion. Legally, abortions can be performed only under four conditions:-
- If continuation of the pregnancy poses any risks to the life of the mother or to her physical or mental health.
- If the fetus has any severe abnormalities
- If pregnancy occurred as a result of failure of contraception in married couples
- If pregnancy is a result of sexual assault or rape
A pregnant woman may or may not undergo an abortion and the decision rests on the doctor. Only a doctor can decide based on the above four conditions if a woman can terminate her pregnancy. There is a need for one registered medical practitioner (RMP) to sign off the consent for an abortion within 12 weeks of pregnancy and two RMPs to sign off for termination of a pregnancy between 12 and 20 weeks.
The pregnant woman may seek for termination of her pregnancy but cannot choose to abort. In such situations, wherein the medical service provider does not consent for an abortion, the woman may resort to unsafe abortion methods. Unsafe abortions are the third largest cause of maternal mortality and morbidity in India.
Unsafe abortion as defined by the WHO is “a procedure for termination of a pregnancy done by an individual who does not have the necessary training or in an environment not conforming to minimal medical standards.” Comprehensive Abortion Care (CAC), a term “rooted in the belief that women must be able to access high-quality, affordable abortion care in the communities where they live and work”, was first introduced in India in the year 2000.
The concept of CAC encompasses care through the entire period from conception to post abortion care and includes pain management.
The 20 week bar on abortions was placed by the MTP Act 1971 to prevent gender prediction testing which was then possible only after 20 weeks of pregnancy.
The aim was to control female foeticide and eugenic abortions. With the introduction and expanded use of ultrasound technology in pregnancy screening in India, foetal sex was detectable in 13 to 14 weeks of gestation.
As a result, sex-selective abortion became rampant. Pre-Conception and Pre-Natal Diagnostic Techniques Act (PCPNDT) was laid in 1994 to ban and punish prenatal sex screening and female foeticide. As a consequence of PCPNDT act and resultant increased rate of maternal mortality & morbidity, need was felt for amendments in abortion law.
The MTP Act was amended in 2002 to facilitate better implementation and increase access to safe abortions for women especially in the private health sector.
Law allows safe abortions till the 20th week of pregnancy. Abortions are not prohibited merely because it is beyond 20 weeks of gestation. Exceptional cases withstand a plea in the court for decisions based on the medical evidence provided by the medical fraternity. In some cases of maternal and fetal indications, decisions have been in favor of safe abortions whereas restricted in some cases of pregnancies resulting from rape or sexual assault.
The woman’s will has no authority over decision of abortions beyond 20 weeks of gestation though recent advancements in medical technology assure safe late term abortions.
The Ministry of Health and Family Welfare released a draft of the MTP (Amendment) Bill 2014, which proposes changes that could initiate a shift in the focus of the Indian abortion.
This Bill proposes to bring about significant changes in the scenario of abortion care, and at the same time, marks a step towards a more women-centric, rights-based abortion law in India. Keeping in mind that technology can detect some fetal anomalies only after 20 weeks of pregnancy and the possibility of safe abortions thereafter, the bill proposes to extend the gestational age limit for abortions from 20 weeks to 24 weeks.
The 20 week window period is insufficient to detect fetal abnormalities. WHO reported that about 17 lakh children are born in India with defects. This could be avoided if the gestational window period is extended up to 24 weeks. The bill proposes extension of abortion to the limit of 24 weeks in accordance with the theory of fetal viability.
Women seek termination of pregnancy later than 20 weeks for a variety of medical and social reasons. Detection of fetal anomalies, Poverty, illiteracy and socially disruptive life are the common reasons for a pregnant woman to seek for an abortion beyond 20 weeks of pregnancy.
Abortions that take place this far long are only 1% and circumstances bear the choice to end a pregnancy beyond 20 weeks. Medically, identification of major anatomic and genetic anomalies of the fetus have been main circumstantial reasons to end the pregnancy after screening and diagnostic testing later in their second trimester.
Late term abortions due to circumstances of unprepared pregnancy, single motherhood, financial constraints and relationship variance are societal concerns that need to be addressed primarily.
Some of the common medical reasons for late term abortions are Polycystic ovarian syndrome (PCOS), Intra uterine growth retardation (IUGR) and detected foetal anomalies such as anencephaly, Down’s syndrome, Dandy walker syndrome, hypoplastic left heart syndrome, congenital diaphragmatic hernia etc., one or more of the factors leading to nonmedical reasons for late term termination of pregnancy are, woman being young, having no income, physical /substance abuse and depression.
Though a pregnant woman may seek for an abortion, the woman’s right for an abortion is not regarded as universally valid and is always viewed and analysed with related medical and social factors.
Medically, abortion is explained as termination of pregnancy before the period of foetal viability. This point wherein the foetus has the chance of survival outside the uterus is termed as foetal viability. This means that a baby born at a particular stage of development before the optimal period of 42 weeks can be saved. Medical advancements have made it possible for babies born as early as in 24 gestational weeks to survive and grow. The stages of foetal development substantiates the medical point of foetal viability.
Conception begins with the germinal stage where in the fertilized egg known as the zygote undergoes cell division and grows in the Fallopian tube. Following this, along with continued rapid cell division and growth there is characteristic differentiation of cells. At this stage, the zygote becomes a blastocyst.
It is remarkable that it is so common for cells from one individual to integrate into the tissues of another distinct person.
The blastocyst arrives at the uterus and attaches itself to the inner wall of the uterus through the process of implantation. The blastocyst consists of two major layers of cells. The outer layer forms the placenta and the inner layer grows in to an embryo.
The umbilical cord grows from the embryonic tissue and connects with the placenta. The physical connection between mother and foetus is provided by the placenta, built of cells from both the mother and foetus, which serves as a conduit for the exchange of nutrients, gasses, and wastes.
Cells may migrate through the placenta between the mother and the foetus, taking up residence in many organs of the body including the lung, thyroid, muscle, liver, heart, kidney and skin.
The embryonic stage starts with the beginning of the third week from conception during which the mass of cells become distinct as human. The embryonic stage plays an important role in developing the nervous system.
The head, followed by the eyes, nose, ears and mouth are quickly formed and activity begins with cardiovascular system as the blood vessels start to pulse.
Fifth week marks the appearance of buds for the development of arms and legs. By the beginning of eighth week, joints and all organs except sex organs are formed and the embryo is about 1 gm in weight and 1 inch in length. Well defined peripheral and central nervous system are developed and neural networks are established towards the end of the embryonic stage. Completion of cell differentiation in the embryo marks the beginning of the foetal stage.
The fetal stage starts from the ninth week and lasts until birth. There are more important changes in brain. By the 12th week, reflexes emerge and foetus makes reflexive motions of arms and legs.
The pregnant mother starts feeling the foetal movements inside her womb. The foetus continues to grow in length and weight. Sex organs are differentiated, heart beat grows stronger and nails, eyebrows and eyelashes form. The foetus increases about 6 times in size by the end of 12 weeks.
The importance of prenatal development post first trimester lies in higher responsiveness of the central nervous system and maturity of the brain.
From the end of second trimester, the foetus continues to grow and put on weight till the time of birth. By 24 weeks, foetus is about 11 and a half inches long and steadily gaining weight. Hearing becomes highly sensitive around the 24th week and the foetus can recognize noise and voices by the beginning of 26 weeks.
The foetus prepares itself for the outside world. Lungs expand and contract to train the respiratory muscles for breathing at birth. Preterm birth any time after 24 weeks is considered viable for the new born to survive under neonatal intensive care. The preterm neonate with minimal required birth weight and complications being ruled out has higher rates of survival and growth.
Maturity of various organs mainly the heart, liver, kidneys and eyes is attained only during the last trimester of pregnancy. Foetal viability and chances of survival depend not only on the gestational age but also on birth weight and health of the new born.
While foetal development is a daily gentle reminder of prospective motherhood for the pregnant woman who looks forward to holding her child in her arms, it sadly may be a warning notice in rare cases of unwanted pregnancies or with fatal maternal/foetal indications.
While there is no denying that MTP can be an emotionally disturbing procedure in many women to voluntarily abort a child, it is highly devastating for her to involuntarily carry through her unwanted pregnancy.
It is equally distressing for a woman to give birth to a child with defects and live through it in situations of financial insecurity and unsupportive relationships. Forcing a reluctant mother to go through with a pregnancy is of no good.
The extension of gestational limit up to 24 weeks could set off argumentative conflicts on eugenic and sex-selected abortions. On the contrary, it would be necessary to know why women consider such pregnancies unwanted.
Women have come a long way since days when abortion was an illegal, secretive and socially unacceptable procedure, hidden from family members. The socially favorable circumstances following legalized abortion and the patient’s relief of getting rid of the unwanted pregnancy out shadows feeling of guilt that used to accompany an illegal and socially stigmatized procedure.
Abortion being a polarized subject, may never have an unanimous acceptance. A woman’s perspective on abortion as an interference with her body for a cure within safe medical limits may narrow down the necessary amendments to the present MTP act. Extension of abortions up to 24 gestational weeks is a step forward towards legislation working in sync with latest advancements in medical technology, widening accessibility of safe abortions and a feminist advantage of a woman’s authority over her body.