How Fetal Viability Is Misunderstood

TOn June 24, Roe V. Wade was overturned. This marked the beginning of a new era as a Maternal/Fetal Medicine doctor. We care for anyone who is at high risk of becoming pregnant. This can be due to a condition like breast cancer, diabetes, or a genetic or anatomical problem. High-risk pregnancies physicians share the belief that the best is possible but can also prepare for what could happen. Over the past 12 years, thousands of our patients have been treated. Most have had a successful birth and a normal pregnancy. Some patients have had to endure the worst, even with all our best efforts. We have shared the grief of mothers who died in childbirth or during pregnancy, and we also mourned the death of highly-desired pregnancies. For these reasons—not to mention the fundamental principal in medical ethics of patient autonomy (the right of patients to make their own decisions about their body, even if the doctor disagrees or the decision goes against medical advice)—abortion care goes hand-in-hand with high-risk pregnancy care.

In fact, many high-risk pregnancy providers also provide abortions for pregnancies that were initially highly desired, sometimes to save their patients’ lives and sometimes because their patient’s fetus has severe genetic abnormalities or birth defects incompatible with life after birth. Other times, we provide abortions because of complications like life-threatening vaginal bleeding, an abnormally dilated cervix, or broken bag of water during what is called the “previable period.”

Understanding fetal viability is essential in understanding the length of the previable periods. Fetal viability does not begin when the small collection of embryonic cells that may eventually become a heart starts pulsating at 6 or 7 weeks’ gestation. If there’s a baby, the term fetal viability refers to the stage of pregnancy at which survival is possible. Though there is no universal consensus, currently in the U.S., fetal viability is thought to be at approximately 6 months of pregnancy (23-24 weeks’ gestation), though some hospitals offer aggressive treatment for babies born at 22 weeks gestation and survival has been reported as early as 21 weeks. Despite rapid advancements in care for newborn babies over the last few decades, babies born before viability—even those at the cusp of viability—cannot survive after birth.

Maternal and Fetal Medicine doctors are fortunate in that Rhode Island has codified abortion as a state right. This means we can continue to provide high-risk care for pregnant women, such as offering or providing them with abortions. Our friends and colleagues who work in states where there are no laws to support abortion have seen their lives change dramatically since Roe v. Wade. These laws prioritize the continuation of previable pregnancies—those that may have a heartbeat but have zero chance of survival should birth occur—above the health and autonomy of an actual, living pregnant person. Ectopic pregnancies are not exempted from some of these laws. These are those that may have a beating but are located outside the uterus. They are considered life-threatening and cannot be terminated at any stage. The Biden Administration announced July 11 that hospitals are required to provide abortions when the mother’s life is in danger. In these instances, federal law prevails over state bans.

According to these colleagues, obstetrics is now like being back in the Middle Ages. They have already watched women with previable pregnancies hemorrhage during an early pregnancy loss, waiting for either the embryo’s heart to stop beating or for the mother to lose enough blood to feel legally justified to proceed with a simple, safe procedure to remove the pregnancy tissue. They have watched women with previable pregnancies partially deliver fetuses through abnormally dilated cervices, again waiting for the fetal heart to stop beating or for the mother to be sick enough from a preventable infection to be legally justified to help what has started—a previable delivery—continue. Although they can offer abortions, they cannot accept pregnancies with severe fetal anomalies.

These common scenarios could have been devastating to pregnant women before June 24, 2022. But the abolishment of Roe v. Wade has eliminated many of our patients’ agency about their pregnancies and reduced our ability as high-risk pregnancy providers to provide abortions when they are medically recommended or personally desired. Policymakers’ deliberate decision to prioritise the health of a healthy fetus over the welfare of the woman who is pregnant is both medically flawed and socially unacceptable.

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