Sometimes, something goes wrong during a pregnancy that leads to the difficult decision of whether to continue or terminate the pregnancy. While it’s not considered a clinical term, the phrase “termination for medical reasons” is sometimes used to describe these types of abortions.
“We care for individuals who terminate pregnancies for a variety of reasons, including fetal anomalies,” says Dr. Siripanth Nippita, director of the division of family planning and clinical associate professor in the department of obstetrics and gynecology at NYU Langone Health in New York City.
It’s important to note that terminations for medical reasons are abortions, and many clinicians say they should not be viewed as “better” than any other type of abortion. It’s all simply reproductive health care. However, the recent Supreme Court decision to overturn Roe V. Wade may affect a women’s ability to terminate their pregnancy, regardless of the reason, depending on where they live.
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What Is TMFR? Termination of Pregnancy for Medical Reasons
Dr. Jeffrey Marcus, a board-certified obstetrician-gynecologist with North Atlanta Women’s Specialists in Georgia and chief medical advisor at Femasys, a biomedical company specializing in minimally invasive, in-office technologies for reproductive health, explains that “termination of pregnancy for medical reasons, or TFMR, is when a pregnancy is ended due to a structural, genetic or chromosomal abnormality of the baby or when continuing the pregnancy would risk the health of the mother. For many women, this outcome may be unimaginable and the decision to undergo TFMR is often made after careful consideration.”
The need for TMFR can arise during any stage of the pregnancy, Marcus says, and they’re relatively rare.
Dr. Greg Marchand, a board-certified OB-GYN and gynecologic surgeon who founded the Marchand Institute for Minimally Invasive Surgery in Mesa, Arizona, says that cases where the pregnant person’s life is in danger are “extremely rare. I’ve seen two of these circumstances out of the over 10,000 pregnancies that I’ve been involved with during my career,” he says.
Recent hard data about the rates at which wanted pregnancies are terminated for medical reasons are difficult to come by. Data gathered during a 2004 survey conducted by the Guttmacher Institute, a pro-choice research organization based in New York, found that of the 1,209 abortion patients included in the study, a total of 7% cited health reasons as the most important reason they had the abortion. Of that total, 4% said they had the abortion because of their own health issues, while 3% said possible problems affecting the health of the fetus led to the abortion.
The Centers for Disease Control and Prevention report that in 2019, the most recent year for which data are available, 629,898 legally induced abortions were reported in the United States.
Termination Related to Fetal Anomalies
What’s more common is for a pregnant person to discover that there’s a fetal anomaly, or an abnormality with how the fetus is developing. “It’s not at all rare to be in the unfortunate situation of having a pregnancy that has severe birth defects or that has something that’s either not compatible with life at all, or that won’t live once it’s born, won’t live very long or won’t have much quality of life after the baby is born,” Marchand explains.
One condition that may develop in utero that would suggest the fetus will not survive to term or not be viable after birth is anencephaly, a very serious neural tube birth defect in which the baby is born missing parts of the brain and skull. The CDC reports that an estimated 1 in 4,600 babies is born in the United States with anencephaly. Whether or not termination would be allowed with these cases in states that outlaw abortion depends on the state.
TFMR is also sometimes used when Down syndrome, a genetic condition that’s also called trisomy 21, is detected in utero. Down syndrome is the most common chromosomal disorder, and the CDC reports that every year, about 6,000 babies, or about 1 in every 700 babies, are born with the condition. Termination in these cases is not legal in states that outlaw abortion.
Congenital heart defects and other problems such as hearing loss and eye disease are also common among these babies. A 2020 study estimates that prenatal testing has halved the number of babies born with Down syndrome in Europe, and a similar 2015 study estimates that in the United States, the number of babies born with Down syndrome had dropped by 30% as a result of TFMR. Termination is in these cases is not legal in states that outlaw abortion.
Prenatal exams and testing can often identify birth defects while the fetus is developing, and thus, some doctors will recommend that an abortion be conducted when such issues are discovered. “The decision to undergo a procedure or induction is often based on patient preference,” Nippita says.
In cases like this, the termination is not considered “‘medically indicated.’ That would be an elective termination,” Marchand says.
Still, it can be a difficult decision to make, Marcus says, and “since the decision to pursue TFMR is complex, every person’s unique situation is taken into consideration when recommendations are given.”
Once the patient has had a chance to digest the information about the baby’s health condition, “it’s really just a personal decision of whether you’d want to terminate or go through the pregnancy if the baby is not going to survive.”
When the Mother’s Life Is at Risk
Marchand notes that in situations where the mother’s life is at risk, he makes sure he’s done his research ahead of time and has the best data available about the condition, survival rates, possible treatments and any other relevant information that can help the pregnant person make the best decision for them.
“I’m going to be bringing in any specialists that can add anything to the discussion,” he notes. In cases where the mother’s life might be in danger, he works with maternal-fetal medicine specialists, who are OB-GYNs that have had additional training in high-risk pregnancies. They can advise the mother about “everything we would do to try to keep her alive if she decided to try to go forward with the pregnancy.”
Conditions that may threaten the life of the mother include:
— Severe infections.
— Heart failure and other serious heart conditions.
Marchand notes that these conversations aren’t easy for the provider or the patient, and many factors must be taken into consideration, such as who will care for any other children the mother may already have if she dies.
“This is extremely difficult counseling to do. It’s very important to include all the specialists that are involved with the care. And most importantly, don’t tell the patient things you don’t know.” By that he means, it’s often difficult to say with certainty how a health situation might play out over time. “With pregnancy, lots of times there’s no way to really know what’s going to happen. You’ve just got to give them the best information you can.”
He encourages physicians who are faced with such situations to think about what they would say when the patient asks “what would you do?” — because the patient will ask. “The patient deserves the best counseling that you can give.”
How a TFMR Is Performed
Typically, a termination that’s related to medical concerns is conducted as a surgical procedure. Marchand says in most cases, the person “didn’t get the diagnosis of being pregnant until past the point where it could reasonably be done with medical therapy,” which is about 10 weeks.
To terminate a pregnancy early on, medical abortion may be an option. In these situations, two medications, mifepristone and misoprostol, are used. These drugs “can induce the uterus to empty its contents,” Marchand says. “Essentially, it goes into labor to miscarry very early on and avoid surgery.”
Marcus notes that “other medications may be given to minimize discomfort,” that can arise from contractions of the uterus caused by the medications.
Abortion with pills is “the preferred method in the cases where it can be used,” Marchand says, as surgical procedures add a risk of infection and potential other complications.
However, in many cases, the pregnancy is already too far along for medical termination to be conducted and a surgical procedure is the preferred approach. There are a few ways that can be accomplished.
The legality of each type of abortion varies by state.
— Dilation and curettage.
— Dilation and evacuation.
— Induced labor.
Dilation and Curettage
If the pregnancy is less than 14 weeks along, typically, the uterus is emptied using an approach called a dilation and curettage, or a D&C.
In this procedure, the doctor dilates the cervix to gain access to the uterus and then uses a tool called a curette, that Marchand describes as being “basically like a spoon that’s used to gently scrape the walls of the uterus.” This is important because all of the uterine contents need to be removed to terminate the pregnancy.
“Particularly if you were to leave some placenta stuck behind, the patient could still have pregnancy symptoms and might even need a second surgery,” he explains.
Dilation and Evacuation
For pregnancies that are beyond 13 or 14 weeks, an extraction, also sometimes called a dilation and evacuation, or D&E, is typical. This is a bigger surgical procedure and “the danger level is going to be a little higher here because it’s not like an earlier fetus, which is mostly cartilage and can be removed through a suction tube,” Marchand says.
Both of these surgeries are typically performed as outpatient procedures; the patient will have a rest period after the procedure where the clinician will monitor them to make sure there’s no unexpected bleeding following the procedure. But, typically the patient can go home the same day.
“I perform these regularly for patients that have miscarriages or babies that have passed away, and they almost always go home right afterwards. Complications are very rare,” Marchand says.
Another alternative for pregnancies beyond 14 weeks is to induce labor. “That’s something that would need to be done in the hospital,” Marchand says.
The patient would be admitted to the hospital just like they would when delivering a full-term baby. However, because of the fetal anomalies and/or because the induction occurs before the fetus would be viable outside the womb, this procedure results in a termination. In some cases, an injection is used to stop the fetal heartbeat before the induction begins.
After any abortion, the patient is typically told “not to put anything in the vagina for one week,” Marchand says, and most clinicians want to see the patient again in a week or so to follow up and make sure there have been no problems or signs of infection, such as a fever.
“As part of the healing process during and after the procedure to help with grief, families are encouraged to talk to their providers about emotional support resources that are available to them and discuss whatever else they may need during this stressful time,” Marcus says.
Who Can Help With TFMR?
Marchand recommends that patients needing abortion care seek out a board-certified physician who can perform termination procedures.
You can also find a local clinic. There are more than 600 Planned Parenthood health centers across the country, ones in states where abortion is legal that provide this care. For surgical abortions at Planned Parenthood, a doctor or nurse may perform the procedure. Depending on the state, advanced practice clinicians, such as nurse practitioners, physician assistants and nurse-midwives, are allowed to perform procedural or medical abortion, though most states require a licensed physician.
In short, there are options available for those faced with TFMR. “To many women, TFMR feels taboo and leaves them feeling lost and overwhelmed with grief, shame and guilt,” Marcus says. But he wants you to know that “many providers are here to help and are available to talk about all of the options that exist along your entire reproductive health journey.”
He encourages anyone who’s deciding whether to undergo a TFMR to speak with their provider about all of their options including the potential impact on future pregnancy and resources for counseling. Hospitals and clinics that provide obstetrical services typically have trained counselors and counseling resources available for patients who undergo TFMR, and “TFMR support groups have recently grown online and can be a great resource for information and needed support.”
What’s Ahead for TFMR?
On June 24, 2022, the Supreme Court of the United States overturned the landmark 1972 decision Roe v. Wade, a nearly 50-year-old precedent that made access to abortion in America a constitutional right. With the recent ruling, the right to access abortion care in the U.S. is no longer protected at the federal level. This significantly impacts a woman’s ability to receive an abortion, even when the procedure is medically recommended.
“Termination of pregnancy will be now be governed by individual states, thereby creating differing standards for ‘termination of medical reasons,'” says Urvashi Bhatnagar, the vice president of business development and health care at the consulting firm Genpact.
This means women with underlying conditions they had before getting pregnant, women who had health conditions appear during or because of their pregnancy and women whose fetus would not survive outside the womb may not be allowed to terminate a pregnancy unless their doctor thinks they are in danger of dying.
According to the Guttmacher Institute, since the Supreme Court overturned Roe v. Wade, 13 states (Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah and Wyoming) have trigger laws in place banning abortion, that either took effect immediately or within 30 days. The timelines for action and the specifics of the changes to abortion access vary depending on the state and the law. More information is available on the Guttmacher website.
Some states that prohibit abortion make exceptions for medical emergencies or if it would save the women’s life, such as Arkansas, Kentucky, Idaho, Louisiana, Mississippi, North Dakota, South Dakota, Texas, Utah and Wyoming.
What situations count in these ‘exception in cases of life or health risk’ clauses is up to the discretion of the physician. In states such as Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and Utah, a doctor can be jailed if the prosecution later finds the abortion they performed not medically necessary.
In other states, nothing will change or laws may be enacted to protect abortion rights — it really all depends on the state.
“Ultimately, this decision is unimaginably challenging for women who are recommended termination for medical reasons, starkly bringing to light the health equity and access barriers that women of reproductive age face,” Bhatnagar says. “High-income women may be able to travel to states that support termination of pregnancy, while others may be unable to do so. Aside from the social and economic factors that are involved in planning for a birth, mothers unable to access, afford or advocate for their own care may be faced with planning for the future for children that may be born with significant medical issues that compound their preexisting socioeconomic and health equity challenges.”
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What Is TFMR? Termination of Pregnancy for Medical Reasons originally appeared on usnews.com
Update 06/28/22: This story was previously published at an earlier date and has been updated with new information.