Unpacking late-term abortion in Australia
How much do you know about abortions that happen later in pregnancy?
This article discusses abortion.
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Conversation around late-term abortion has been reignited following the introduction of Liberal MLC Ben Hood's private member's bill to the South Australian upper house late last month.
MLC Ben Hood introducing his private members bill into the South Australia Legislative Council.
On Wednesday, the bill was put to a conscience vote in the South Australian senate.
It was defeated by one vote.
But how much do Australians know about late-term abortions?
What is a late-term abortion?
Late-term abortion generally refers to the termination of a pregnancy after 20 weeks of gestational age.
At this stage, a fetus is advanced in its growth, and questions of whether it can survive outside the womb are commonly discussed.
Victorian private hospital manager and midwife Karelle Kunst says a late-term abortion is from 20 weeks pregnant.
"Everything changes from 20 weeks."
"Our whole guidelines change".
"If you have a miscarriage before 20 weeks, it's called a miscarriage, but if you're 21 weeks, it's then called a stillborn." "That baby gets a birth certificate, and it needs a funeral, and it gets cremated. It actually becomes an actual child once it's 20 weeks."
MSI Australia Director of Clinical Excellence, specialist gynaecologist and sub- specialist in sexual and reproductive health Dr Catriona Melville, says she doesn't like using the terms 'early' and 'late' because it "apportions blame to people”.
"I prefer to name it as the gestations at which people have terminations, like first trimester, second trimester, [or] 20 weeks, 16 weeks."
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What is the law on abortion after 20 weeks?
Today, women can legally get an abortion for any reason before they reach a certain number of weeks in their pregnancy, as dictated by laws in each state and territory.
After this point, abortions need to meet other guidelines which are set out in each jurisdiction’s laws.
Laws in each jurisdiction outline what doctors need to consider when approving an abortion after the set number of weeks.
These reasons include the woman’s “current and future physical, psychological and social circumstances” and “all relevant medical circumstances”.
This is set out in Victoria’s Abortion Law Reform Act 2008 and similarly in other abortion laws across Australia.
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How are late-term abortions performed?
There are two ways an abortion can be performed after 20 weeks gestation.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists’ (RANZCOG) guidelines on abortion care, recommend feticide should be considered “at or beyond 22+0 weeks pregnant or based on local jurisdictional guidelines”.
Feticide is the process of stopping a fetus’ heart via a lethal injection.
After feticide is performed, the fetus can be either surgically removed or delivered.
The surgical method is called dilation and evacuation and is performed from 14 weeks onwards.
Before the procedure, the woman’s cervix is widened using specific drugs, a process which can take more than a day.
Once the cervix is wide enough, the fetus and placenta are removed with forceps and suction.
The second and most common late-term abortion procedure is a medical induction abortion.
This is where labour is induced and a woman gives birth to the fetus.
Two drugs allow this to happen: mifepristone, which blocks hormones called prostaglandins, and misoprostol, which causes the cervix to open and the uterus to contract.
This becomes standard procedure after 24 weeks.
RANZCOG guidelines on abortion care say women should be able to choose whether to have a surgical or medical abortion between 14 and 24 weeks gestation.
Yet, Dr Catriona Melville says there are “very few” providers nationally who will do this surgical abortion procedure.
“So, if somebody has a preference for that, and bearing in mind that's only usually done to 22 or 24 weeks, it can be very challenging to find a provider."
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Why are late-term abortions performed?
The reasons why late-term abortions are performed are complex.
The Royal Women's Hospital told The City Journal they are currently the only provider of abortion after 24 weeks in Victoria.
"The decision to have a late abortion is incredibly difficult for families to make," they said.
The ABC has reported on the experience of South Australian Tayla-Jane Jackson, who had an abortion at 27 weeks and 6 days gestation.
They say two doctors agreed that Ms Jackson would be at risk of mental harm if she had her baby.
Ruth Milne chose to terminate her baby Asha at 30 weeks gestation.
She said her baby had triploidy and doctors were surprised her baby was still alive.
“Carrying a baby with triploidy also poses significant risks to the mother,” said Ms Milne.
In another case, a fetus was aborted at 24 weeks after a late diagnosis of Down Syndrome, according to a Guardian article .
The same article reports that an abortion took place at 28 weeks following a worsening diagnosis of spina bifida.
"Sometimes we don't get diagnoses of fetal anomalies, something seriously wrong with the fetus, till later in pregnancy,” says Dr Catriona Melville.
She says the most pressing situations where late-term abortions occur are those concerning the “life or death of the pregnant person”.
“That could be anything from somebody with a cardiomyopathy, which is a heart problem, who could go into heart failure, and pregnancy takes a very big toll on somebody's physiological system."
According to Women’s Health Victoria , abortions after 24 weeks are often performed on wanted pregnancies with difficult circumstances, frequently involving fetal abnormalities.
They say women who ask for abortions so late in their pregnancies are often women who are vulnerable.
“This includes women who due to youth, medical conditions, or family violence have been unable to access support earlier.”
Some medical professionals, however, do not agree with why late-term abortions are performed..
Dr Melissa Lai is a senior neonatologist and Director of Pro-Life Health Professionals Australia.
She says feticide is an elective procedure and not “indicated for any maternal medical complication of pregnancy”.
“It is never medically necessary to deliberately cause the death of the fetus, in order to save the life of the mother,” she says.
“In a true maternity medical emergency like pre-eclampsia , feticide is never performed as standard practice, because the priority of obstetricians and midwives is to proceed directly to delivering the baby as soon as possible.”
She says evidence that supports feticide due to the fetus having an anomaly, is biased and doesn't answer the question, “is feticide the best course of action in cases of lethal fetal anomaly?”
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Are babies born alive after abortions?
The RANZCOG guidelines on abortion care say, from 22 weeks and zero days pregnant, “a live birth becomes increasingly common when performing an abortion”.
Babies can be born with signs of life following a medical induction abortion, where parents have decided not to have a feticide before inducing labour.
Kathryn has been a midwife for 34 years and currently works as a maternity unit manager in a private hospital.
She says babies can sometimes be born alive after abortions.
“Misoprostol usually causes the baby to die because of the really strong contractions, but in some instances, the baby can still be born alive.”
"But they won't survive," she says.
“We don't actively check for signs of life unless they're visible to us at the time of birth. We don't want to make the situation more traumatic for the parent.”
Representing RANZCOG in a Queensland hearing , maternal-fetal medicine specialist Dr Elisha Broom explained circumstances where babies are born alive after abortions.
She said the only babies who are born alive after abortions in Queensland, are those beyond 22 weeks gestation with lethal fetal anomalies .
She said this is because some parents "want to meet" their baby and there is a "palliative care intention".
Queensland's guidelines on termination of pregnancy say, when feticide is not performed, a medical team should plan palliative care for a baby with a life limiting condition.
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How many late-term abortions are performed in Australia?
South Australia is the only Australian jurisdiction which publishes annual abortion data.
According to their 2023 Annual report , 0.96 per cent of South Australian terminations were after 22 weeks and 6 days gestation.
Forty-seven fetuses were aborted after 22 weeks and 6 days gestation.
Thirty-seven of these were for the "physical or mental health of the pregnant person".
Ten of these were because of fetal anomalies.
As South Australia's laws on abortion after 22 weeks and 6 days only came into effect in July 2022, the state only has data after this date.
It is generally accepted that, like in South Australia, late-term abortions make up around 1 per cent of all abortions.
According to the Guttmacher Institute , 93,800 abortions took place each year from 2015 to 2019.
An estimate from the Medical Journal of Australia says 88,287 abortions took place from 2017 to 2018.
This means the number of late-term abortions performed each year could be around 883 to 938 Australia-wide.
It is important to note, however, that late-term abortion was not legal in some states and territories during those time periods.
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Why don’t we know more?
Late-term abortion is a controversial topic in Australia.
A lack of consistent and comprehensive reporting on abortions means questions about how many late-term abortions occur and the reasons why they do, is debated.
"It was fantastic that abortion was decriminalised, but some of the states didn't mandate any data collection in their law," says Dr Catriona Melville.
She says national data would allow us to see abortion trends, which would stop us guessing about the number of abortions that occur.
"I think data is very empowering," she says.
