CHAPTER 5 THE PREGNANT WOMAN and HER FETUS

5.1 SUPPORT for PREGNANT WOMEN

Pregnant women and their partners are usually committed to main­taining a healthy lifestyle. Pregnant women are often supported by their partners once they understand what they endure during pregnancy and recognize their own fears and needs as fathers. The expertise of obste­tricians and midwives ensures the outcome of most pregnancies in de­veloped countries is without complications. Women in the lower socioeconomic bracket usually receive prenatal care but they would have less chance of access to prenatal care givers of their choice.[1]

Once women know they are pregnant, their future offspring are important for them, but more so after they feel their first movements which reinforce the bonding between them. From this stage mothers are keen to protect them. Restrictions on lifestyle are usually accepted to enhance prospects for the birth of a healthy child. Pregnant women have a right to all relevant information and to be involved in decisions relat­ing to delivery, especially caesarean sections. There is evidence that this is not always the case and that women are dissatisfied with this neglect.[2] The anxiety of a pregnant woman is not allayed until she learns the good news that her baby is healthy.

Women who need the greatest emotional support and comfort are those who have recently had a stillbirth or a late miscarriage. Each woman who has experienced a pregnancy loss has unique physical and emotional needs. Depending on how early the loss occurs, parents should be encouraged to hold, cradle, and weep over their deceased child. It is good for the family to experience mourning openly, to name their child and discuss their attitude to a religious service for their child with their relations and friends. Even when not required by law, mothers who wish to have a burial service for their fetus have a right to require it. Even­tual autopsy results for a stillbirth should be given to the family sensi­tively. Genetic counseling, by assessing the risk of abnormality in future pregnancies, could assist in making a decision on whether, and when, to plan another pregnancy and thereby offset any undue influence of feel­ings of grief or guilt.[3]

Instances of ambiguous attitudes of older children on the mother’s return home after a stillbirth should not be taken personally because the negativity displayed is merely a sign of the experience of their own shock and grief at the loss of a baby sibling. At times children may show signs of unsupported dependency, quite oblivious of their mother’s loss and deep personal grief. The mother and the father may require support and counseling from a professional to cope with feelings of misplaced guilt, fear, anger, and sadness.

5.2 EMBRYONIC and FETAL MORTALITY and MORBIDITY

Before dealing with the ethical dilemmas of decisions involving the loss of human fetuses, it is necessary to learn the scientific facts concerning the incidence and causes of fetal losses before considering our ethical responsibilities to prevent them. Research by Allen Wilcox and col-leagues has shown that of 221 healthy women trying to conceive in 707 menstrual cycles, 198 (28 percent) achieved a “biochemical pregnancy” as indicated by a highly sensitive and specific assay for elevated levels of a pregnancy hormone – human chorionic gonadotrophin (HCG) – in urine specimens before the first missed menstrual period.[4] The HCG is produced by the trophoblastic cells of blastocysts a week after fertilization when the process of implantation begins. Of these 198 women 43 (22 percent) lost their embryos before pregnancy could be clinically recognized. Only 155 women out of the original 221 (70 percent) had a clinically recognized pregnancy during the 9 months of the study. Subsequently 19 of the 155 clinically recognized pregnancies miscarried at the mean gestational age of 11 weeks, i.e. 12 percent. The total loss of biochemically detected pregnancies from the blastocyst stage was 62 (43 + 19) out of 198 i.e. 31 percent.[5] The 12 percent loss after implantation is close to the generally quoted 15 percent loss by spontaneous abortion for all recognized pregnancies.[6] Of the 221 women in the trial, 23 (10 percent) failed to achieve a biochemical pregnancy. Of the women who had an early loss of pregnancy 95 percent conceived again and had a clinically recognized pregnancy. Most women (124) became pregnant during the first three cycles with a 25 percent probability of achieving a clinically recognized pregnancy per cycle.[7] There is evidence that the risk of early pregnancy loss increases when implantation occurs 9 or more days after ovulation.[8]

Wilcox admitted his methods could not detect losses of early embryos before the blastocyst stage and offered no reasons to explain why in up to two-thirds of cycles no biochemical pregnancies were detected.[9] Peter Braude and his fellow researchers suggest that the reasons may include anovulation, failed fertilization or preimplantation losses before HCG is produced.[10] Failure of fertilization could be due to genetic faults in the formation of sperm or egg during meiosis, the postovulatory ageing of ova before fertilization, or other causes of infertility in the sperm or egg.[11] Michelle Plachot agrees with Braude and cites evidence to suggest that genetic faults in egg or sperm account for about 40 percent of preim­plantation embryos affected by a chromosome anomaly in normal and IVF embryos.[12] The above suggestions are in agreement with the find­ings of Mark Sauer and his colleagues who found that of 41 ova recov­ered by uterine lavage from fertile women, 10 were undivided, 20 did not go beyond the 2–18 cell stage, one not beyond the morula stage, and only 10 (25 percent) developed to the blastocyst stage.[13] John Biggers estimates that 50 percent of embryos naturally conceived are lost by the time pregnancy is recognizable.[14]

Inspection of spontaneous embryonic and fetal abortions provides evidence that most of them are afflicted by congenital abnormalities. The incidence of gross chromosomal anomalies in spontaneously aborted fetuses in the first trimester ranges from 62–80 percent, but falls to about 25 percent in the second trimester. These may be caused by chromoso­mal or environmental factors (e.g. drugs), or a combination of both. About 5.4 percent of all clinically recognized pregnancies are affected by a chromosome abnormality and this would account for 32–42 percent of all spontaneous embryonic and fetal deaths.[15] Other causes include the effect of increasing maternal age on ova, vitamin deficiencies, cardiac disease, infection, viruses, e.g. rubella, stress, hypoxia and fetal growth retardation, poor placental circulation etc. Environmental factors asso­ciated with increased risk of fetal death include teratogenic substances which cause death directly or cause a malformation when fetal organs are being formed.[16]

About 2 percent of pregnancies are ectopic, i.e. they develop outside the uterus, and 97 percent occur in pathological fallopian tubes. They are the main cause of maternal deaths in the first trimester and account for 9–13 percent of pregnancy-related deaths.[17] Expectant manage­ment of subacute ectopic pregnancies results in their resolution without surgery in up to 80 percent of cases by spontaneous tubal abortions or by resorption, resulting in a 30–50 percent probability of not being able to conceive naturally.[18]

Australian research with 585 participating couples has shown that men working in some trades increased the odds of miscarriage in their partners by 1.75 times while there was no difference between women who worked and women who undertook home duties. But for women under 35 years and working at home the risk of a miscarriage was 1.91 times higher.[19] X-rays of the abdomen and back of women were associ­ated with 1.89 times increased risk of miscarriage, and it was 4.28 times higher if their male partners had the X-ray due to its effect on sperm for­mation. Women who are exposed to glues at home had a 1.87 times increased risk of miscarriage while their male partners increased the risk of miscarriage by an odds ratio of 2.36 by exposure to glues, 3.19 to oil paints, and 2.27 to oven cleaners. Exposure to multiple factors further increases the risk of miscarriage.[20] The rate of miscarriage rises from 3.7 percent for couples without exposure to a single risk factor to 75 percent for couples exposed to six or seven factors. The odds ratio of miscar­riage was also found to increase with age over 35 years, 2.46 for women and 2.33 for their male partners.[21]

Evidence of the harm caused by pregnant women who smoke is coming to light. Miscarriages are increased by up to 27 percent and the risk of underweight babies at birth is higher. Their daughters also have a similar increased risk of miscarrying and their sons are likely to be affected by undescended testes. Passive smoking also contributes to these problems, including cot deaths. Children brought up in homes where smoking occurs have a lower birth weight, are shorter, have smaller airways in their lungs, suffer more from asthma and respiratory infec­tions and other symptoms, are fivefold more prone to be affected by aller­gies and are exposed to a greater risk of glue ear. The abuse of addictive drugs and the excessive consumption of alcohol or caffeine also harms the outcome of pregnancies, their offspring, and may increase the mis­carriage rate.[22] Finally recent research shows that unwanted emotional stress caused by serious life events (e.g. death of a child) during the first trimester of pregnancy may cause congenital fetal defects, especially those of the cranial neural crest.[23] Clearly, education in schools on risky behavior to avoid is imperative. It is generally agreed a pregnant woman “is morally obliged to avoid inflicting prenatal injury” on her fetus pro­vided this does not require her to sacrifice other important interests.[24]

5.3 INDUCED ABORTION

Incidence

It is estimated that globally 150,000 abortions are performed each day, equivalent to over 54 million abortions per year.[25] The reported number of legal abortions in the United States was 586,760 in 1972, 1,297,606 in 1980, 1,429,577 in 1990, and 1,267,415 in 1994. The Supreme Court decisions on legal abortion in Roe v. Wade and Doe v. Bolton in 1973 explain this increase but abortions may have been under-reported before 1973 because they were illegal.[26] The estimated number of legal abor­tions in Australia in 1990 was 79,019.[27] The legal abortion proportion per 100 known pregnancies was 9 for the Netherlands (1986), 18.4 for England and Wales (1987), 23 for Australia (1990), 29 for the United States (1985), and 54.9 for the former USSR (1987).[28]

Reasons

 Whatever the reason, abortion is never an easy decision. In developed countries abortions usually occur because of unwanted pregnancies. In the majority of cases the reasons are economic, social, career related, reluctance to be a single mother, a desire to keep the family at its present size, or an inability to cope with another child for personal, health, lifestyle, or domestic reasons. It is sometimes sought after rape, incest, severe psychological trauma, or to save the mother’s life.[29] Jacques Suaudeau links failed contraception to abortion because procreation is not wanted.[30] Some young women have abortions because they find they are unable to cope with continuing a pregnancy. Some single women without family and social support find a solution to their problems by recourse to abortion. Some do not want to tell their parents they are pregnant or to risk letting pregnancy and the responsibilities of motherhood prevent them completing their secondary and/or tertiary education. Many women choose to have an abortion if prenatal diagnosis shows that their fetus is affected by some serious congenital abnormality. Others prefer abortion to giving their child up for adoption. Pressure also comes from their partners who do not want to assume the responsibilities of being fathers or of supporting their children. Mothers, however, find it difficult to decide to have an abortion once bonding is intensified by seeing ultrasound images of their fetuses, especially if their friends shared in their joy.

Surgical and medical methods Postcoital methods

 Currently in the UK during the first trimester the vacuum aspiration method is used in about 99 percent of abortions under local or general anesthetic. It is safe for the mother and lasts less than 10 minutes, and up to 98 percent may be performed as day procedures. The risk of com­plications is low – only one-tenth of the risk of continuing the pregnancy and giving birth. Medical induction of abortion in pregnancies up to 9 weeks’ gestation may be obtained by administering orally mifepristone 600 mg, formerly known as RU 486, followed 48 hours later by oral or vaginal prostaglandins. Complete abortion occurs in 95 percent of cases with 85 percent occurring within 4 hours of treatment, and incomplete abortion in 4 percent. There is a failure rate of 1 percent. Nausea, vom­iting, and diarrhea occur in 30 percent of cases.[31] Surgical evacuation is avoided, except for the 5 percent of patients with incomplete or failed abortion. Doses of mifepristone as low as 200mg also suffice for effec­tive abortion.[32]

During the second trimester two techniques are most frequently used. The first is surgical, cervical dilation with uterine curettage and evacua­tion, which is usually used in the USA. Major complications occur in only 0.4–1.7 percent of cases. The second technique is medically induced abortion using a locally administered prostaglandin. This is the preferred method in the UK. Its complications include vomiting and/or diarrhea, bleeding in 1.7 percent of cases, and incomplete abortion in up to 30 percent of cases. Its action brings on strong and sustained contractions of the uterus which usually cause fetuses to die of oxygen deprivation prior to birth. This lessens stress for the mother and staff. Some maternal deaths have been linked with intra-amniotic administration of prostaglandins.[33] A combination of mifepristone and prostaglandin is also effective as a simple non-invasive method for abortion up to 20 weeks gestation.[34] Finally, third trimester abortions do occasionally occur when lethal or untreatable abnormalities are detected late in pregnancy in viable fetuses.[35]

[5.3.4] Postcoital methods

 Some postcoital methods usually prevent pregnancy by inhibiting implantation and can be used by women who do not wish to become pregnant after unprotected sexual intercourse or when a barrier method unexpectedly fails. Mifepristone is also a postcoital drug which is very effective in preventing pregnancy because it inhibits implantation of embryos. It is marketed for abortion in France, Sweden, United Kingdom, China, Austria, Belgium, Finland, Greece, Israel, and Spain.[36] Recent research show that doses of 10–50 mg of mifepristone are effective.[37]

The insertion of a copper tipped intra-uterine device (IUD) within a week of sexual intercourse is known to prevent pregnancy. Medicated and copper treated IUDs inhibit the process of the embryo’s implanta­tion in the lining of the uterus and may also prevent, or interfere with, the process of fertilization.[38] Copper ions released from these IUDs into the fluids of the uterine cavity and the fallopian tubes may kill sperm and/or egg and thereby prevent fertilization.[39]

Some emergency contraceptive pills (ECPs), also known as “morning after pills,” can prevent pregnancy by inhibiting or delaying ovulation or by rendering the lining of the uterus inhospitable for implantation of an embryo. An example of this is the Yuzpe regimen of oestrogen­progestogen pills which are prescribed by a doctor to be taken within 72 hours of unprotected intercourse and repeated 12 hours later.[40] They may also inhibit transport of sperm or ova.[41] It is most effective in prevent­ing pregnancy when commenced about 12 hours after unprotected inter­course.[42] A survey of 10 clinical trials of the Yuzpe regimen found it 75 percent effective in reducing the number of actual pregnancies compared to the expected number.[43] This means 25 percent of expected pregnan­cies did occur. Another recent example of ECPs is the high dose progesto­gen, levonorgestrel, which is 89 percent effective.[44]

A study involving women of proven fertility showed pregnancy rates for sexual intercourse near the time of ovulation ranged from 50 percent within 3 days of ovulation to 66.7 percent (6 pregnancies from 9 cycles) on the day of ovulation to 20.5 percent 2 days after ovulation. These results were based on self-observation of mucus symptoms, not objec­tive criteria of ovulation. The pregnancy rate for 309 cycles over 8 fertile days was 18 percent but for 197 cycles over 7 days it was 23 percent.[45] In the general population the conception rate of unprotected intercourse per cycle is generally put at 25 percent, at 60–70 percent for six months, at 80–90 percent for 12 months, and 90–5 percent for 24 months.[46] Research which involved 221 women who planned to become pregnant showed that in 625 menstrual cycles for which dates for ovulation could be estimated, 192 (31 percent) conceptions occurred during the 6-day period ending on the estimated day of ovulation. Evidence of conception was based on an elevated level of hCG produced by a blastocyst. If inter-course occurred every other day during these 6 days, the conception rate was estimated to be 33 percent, but it was 15 percent if intercourse ran­domly occurred only once.[47] It needs to be remembered that the timing of the fertile period can be very unpredictable, even for women whose cycles are regular.[48]

Within 5 minutes of sexual intercourse the first batch of sperm reach the fallopian tubes where conception normally occurs.[49] Although the median life of sperm in a woman’s genital tract is 1 to 3 days after inter-course, sperm are able to live in a woman’s cervical crypts for up to 6 days and still be able to fertilize an egg. But an egg is only capable of being fertilized for about 12 hours, and at most 24 hours, after ovula­tion. Most eggs are fertilized by sperm derived from intercourse one or more days before ovulation. It is not surprising, then, to find that an important review article concluded it is likely the Yuzpe regimen mainly works by suppressing ovulation.[50] In fact, research shows the Yuzpe regimen prevents ovulation in 21–7 percent of cases when taken one or more days before the expected ovulation day, whereas progestogen-only ECPs inhibit ovulation in 33 percent of cases when given 3–4 days before ovulation, and possibly even longer.[51]

Contraceptives – abortifacients?

It is ethically necessary to distinguish contraceptive methods which prevent pregnancy by impeding implantation of an embryo from the use of pills which suppress ovulation and/or methods which prevent con­ception. Progestogen only pills, mini pills, prevent conception by inhibit­ing ovulation in about half of the cycles, and in the others by thickening the cervical mucus to block sperm penetration or by thinning the endometrial lining of the uterus, which may impede an embryo from implanting. They also reduce the number, and action, of the cilia (hair-like outgrowths) in the fallopian tube which may slow the transport of the ovum and thereby affect fertilization and possibly sperm capacita­tion and presumably account for an increase in the rate of ectopic preg­nancies above normal.[52] The pregnancy rate per year for perfect users is 0.5 percent but for typical users it is estimated to be about 5 percent.[53] It is not known the extent to which the progestogen-only pills prevent implantation.[54]

The primary mode of action of the combined estrogen-progestogen oral contraceptive pill is the inhibition of ovulation and the thickening of the mucus which makes it impenetrable for sperm and so impedes transport to the fallopian tubes; it also changes the morphology of the endometrium whereby it may be unreceptive to the implantation of an embryo, but this is not its primary mode of action.[55] Since combined pills suppress ovulation more effectively than mini pills, it is no surprise that their method failure pregnancy rate is 0.1–1 percent and for typical users the failure rate is 3–6.2 percent.[56]

There is evidence that in women using progestogen-only pills the ectopic pregnancy rate is about 6 percent, and 0 percent for women using the combined pill [57] As noted earlier, the incidence of ectopic pregnancy in the general population is about 2 percent. This is supported by further evidence that the use of both types of pills at the time of conception were associated with more effective prevention of intrauterine pregnancy than ectopic pregnancy.[58] This supports the view that both pills have a slight undetermined risk of preventing intrauterine pregnancy by impeding implantation.[59] Without providing any scientific evidence of the precise incidence of the prevention of implantation, an important study concluded

These data suggest that the morphological changes in the endometrium of OC users have functional significance and provide evidence that reduced endometrial receptivity does indeed contribute to the contraceptive efficacy of OCs.[60]

John Wilks has shown how oral contraceptives could prevent implanta­tion but does not give any rate of its incidence.[61]

Norplant is an effective progestogen contraceptive implant. It mainly prevents ovulation, thickens the cervical mucus which acts as a barrier to sperm to prevent conception and also thins the lining of the endo­metrium. After a month long trial of 32 sexually active women using Norplant, there was no evidence of blastocysts producing hCG when a sensitive and specific assay was used that can detect hCG as early as 7 days after ovulation. This shows no blastocysts were formed. It was suggested that hostility to sperm penetration of the mucus and impaired maturation of oocytes prevented fertilization when ovulation did occur. It was admitted hCG could not be detected before 5 days in the Norplant group and in the 20 noncontracepting control women of proven fertility who were trying to conceive. It was concluded that early or menstrual abortion was not a part of Norplant’s mechanism of action.[62] A later study noted that Norplant induced an abnormal hormonal milieu which could render fertilization more difficult and that subclinical abortion among Norplant users was very exceptional. It was concluded that subclinical abortion does not contribute to Norplant’s efficacy.[63]

The possibility that both pills discussed may prevent implantation does not imply this occurs. In addition to the direct evidence for Norplant, there is indirect evidence these pills do rarely have an early abortifacient action as a side-effect.[64] However, bearing in mind the high natural losses of early human embryos, scientific grounds are lacking to say that the efficacy of all three contraceptive methods discussed above actually depends on an abortifacient effect. As in the Norplant trial, more accurate results could be obtained by taking relevant hCG readings of three large groups of women, each of which uses one of these contra­ceptive methods.

5.4 LONG-TERM SEQUELAE of ABORTION

A single abortion appears to have little or no significant sequelae or effects on a woman’s menstrual or gynaecological morbidity or on subsequent preterm delivery in teenage pregnancies. In a survey of 690 women who had an abortion in the last 4–7 years, the sterility rate increased from 2 percent in the control group to 3.6 percent. Prostaglandin-induced abortion does not seem to affect cervical competence during future pregnancies, but termination during the second trimester performed by mechanical dilatation of the cervix could result in some longterm damage.[65]

It is difficult to obtain an accurate account of the emotional consequences of induced abortions that are not influenced by the positive and negative attitudes of the authors of studies in relation to abortion itself. The later the termination in the second trimester, the greater the negative psychological sequelae are for the woman. Women who have an induced abortion for social reasons, experience more guilt than those who have a spontaneous abortion. There is evidence that women whose pregnancies are terminated medically experience more guilt than those whose pregnancies are terminated surgically. But women having repeat abortions have a preference for medical abortion, probably on account of its less invasive nature. The experience of guilt and loss of self-esteem by both parents for not having formed a healthy child are compounded by the deliberate decision to terminate a previously wanted pregnancy.[66]Again women who terminate pregnancies following detection of fetal defects experience poorer psychological outcomes and acute grief – up to 20 percent even two years later, not to mention depression and guilt.[67]

Coerced abortion, prior emotional problems, and youth are risk factors for developing adverse psychological sequelae. Postabortion trauma may be provoked by a pregnancy-related event such as friends having babies or political debates on abortion. It may also be increased by a lack of adequate prior information on the adverse sequelae likely to be experienced in subsequent years coupled with the lack of support from family and friends.[68] There is evidence of deliberate infliction of self-harm by those who had a termination or who were refused an abortion. In some cases the degree of psychological harm experienced by women who have an abortion supports the case for continuing, rather than terminating, pregnancy.[69]

Brief periods of distress are commonly experienced after an abortion, but this is not a psychiatric disorder. Many women suffer significant postabortion trauma and seek professional help, but this alone gives no indication of the percentage of women who regret that they had an abortion. Inability to cope with an unwanted pregnancy is central to the problem. The adverse sequelae occurring in women after an abortion are long-term in about 10 percent of cases. At times these sequelae seem to be the flow-on of symptoms present prior to abortion, e.g. emotional instability or history of psychiatric illness. The risk of harm after an abortion is greater among younger women, those with poor social support and those from sociocultural groups which are opposed to abortion. There is also evidence of enduring adverse psychological sequelae in both the mothers and children when abortion is denied.[70] In a Finnish study it was found that the suicide rate after an induced abortion was three times greater than the general suicide rate for women aged 15–49 years. It was concluded that there may be common risk factors for both suicide and induced abortion or that induced abortion may have a harmful effect on mental health.[71]

It seems clear that professional counseling is required to advise women of the likely short- and long-term implications of having an abortion so that their decisions may be truly informed and free. The full implications of abortion for a woman may not become apparent until she has experienced a pregnancy to term. Many questions remain unanswered. Better research conducted on the psychological effects experienced by a broad cross-section of women who have had an abortion would be helpful. Women who experience postabortion depression, grief, and guilt do not return to abortion clinics for counseling, but seek it elsewhere. The need to safeguard informed and free consent prior to abortion seems to require that preabortion counseling should be offered by agencies other than the providers of abortion.

5.5 FETUS with ANENCEPHALY

As we shall see in chapter 7, it is now possible to detect many lethal fetal abnormalities with certainty by about 16 weeks gestation. Examples of untreatable lethal anomalies are some chromosomal defects and anen­cephaly, a neural tube disease, on which I will focus since most newborns with anencephaly die within 12 hours of birth. The normal elevation of the neural tube folds is impeded, leading on about day 24 after ovula­tion to the proximate cause of anencephaly, i.e. a failure of closure of the anterior end of the neural groove which develops into the brain. The posterior end closes on day 28 after fertilization, by which time all neural tube defects are determined. The anterior opening in the tube allows the protrusion of the developing and differentiated brain where exposure to amniotic fluid causes its degeneration and collapse by 8 weeks post ovu­lation. It is thought that the failure of the cranial vault formation is, for the most part, secondary to the initial brain malformation.[72]

The permanent absence of the cerebral hemispheres means that the fetus with anencephaly will never exercise rational and free acts. The brain stem, however, continues to function. It connects with the upper part of the spinal cord and controls automatic functions like respiration and heart beat. The fetus sometimes presents with other nonneural mal­formations of the heart, lungs, pituitary or adrenal glands. It is one of the most frequently found conditions that is incompatible with sustained life, both before and after birth. [73]It has been estimated that the inci­dence of neural tube defects drops dramatically from 2.5 percent of embryos on day 26 to 0.06 percent at term and that most of these are lost by the end of the eighth week. An interplay of environmental and genetic factors is believed to be important for causing anencephaly. It occurs more in Ireland and the UK than anywhere else.[74]

The remote underlying causes of anencephaly are not known for certain. Multivitamins and folic acid must be involved since an increase in their intake prior to the time of conception decreases the incidence of neural tube and other birth defects considerably. The diet of women con­templating pregnancy should include leafy green vegetables since they are rich in folate; or folic acid supplements available from pharmacies should be taken.[75] The original cause of anencephaly may be traced back to a defect involving multiple biochemical metabolic abnormalities, including folic acid, in the third week after fertilization.[76] It seems that there is a genetic predisposition, but not a genetic determination, for anencephaly. Up to 95 percent of these infants are born to families with no previous history of neural tube defects.[77]

In 1975, before prenatal diagnosis was widespread, Australian statis­tics show that of 131 fetal deaths with anencephaly, it is known when 115 died in relation to labor. Of these, 34 died a few weeks before labor had commenced and 81 died during labor. The final weeks of pregnancy, then, are life-threatening for fetuses with anencephaly.[78] In the same year there were 49 newborns with anencephaly of whom 34 died under 12 hours, including 17 who died within an hour of birth, and the remain­ing 15 died in the following week.[79] This means of 180 anencephalic perinatal deaths, 73 percent (131) were fetal and 27 percent (49) were neonatal. Far more fetuses with anencephaly die before birth than after. These facts are important for a complete ethical evaluation.

It can be calculated from Australian statistics for neonatal deaths from anencephaly and similar lethal anomalies for the years 1988–95 that of 139 live-born infants, 119 (86 percent) died within a day (63 of whom died within an hour of birth), 13 (9 percent) died a day later, and the remaining 7 (5 percent) died before day 6.[80] Australia’s live birth rate for anencephaly dropped from 5.1 per 10,000 births in 1985 to 1.7 in 1994. This drop would be explained by the rise in prenatal diagnosis and the rise in the number of reported induced abortions for anencephaly from 3 in 1985 to 84 in 1994.[81]

Labor and delivery of fetuses with anencephaly at term is excessively difficult because brow presentation and shoulder dystocia is likely to cause the baby to be stuck in the birth canal, and cause extreme trauma to the mother as well as a high risk of pre-eclampsia, hypertension, hem­orrhage, and subsequent difficulties in pregnancy or delivery. A caesarean section is usually required on account of unacceptably high risks in labor for the mother. This would usually result in the death of the baby because of a lack of a cranial vault to protect the baby’s brain from sudden expo-sure to atmospheric pressure and tearing as the head is lifted out. Both kinds of delivery would be exceptionally painful for infants with anen­cephaly. They may need tubal feeding or a drip in some circumstances to satisfy their nutritional requirements. They may begin to suck from 32 weeks but lack the ability to do so in a sustained and coordinated way up to term. Some nourishment may be taken from the breast or a bottle for the short period of life at their disposal.

Not even a normal fetus can live outside the uterus at 16 weeks’ ges­tational age beyond a few minutes. The cause of death for a normal infant delivered from 16 to 20 weeks would be an incapacity to inflate the lungs due to lung immaturity. Prior to the use of the neonatal inten­sive care unit (NICU) in England and Wales during 1946–50, all babies weighing <1000g at birth died. This was equivalent to about 28 weeks’ gestation or less.[82] Only 9 percent of infants born alive between 24 and 28 weeks in a large tertiary care center from 1966–1970 survived at a time when intensive care did not include much beyond parenteral infu­sions of glucose and electrolytes.[83] Before the days of NICU, by 29 weeks 30 percent of all newborns were capable of long-term survival, by 30 weeks over 50 percent survived, by 32 weeks over 60 percent survived, by 33 weeks at least 66 percent survived, and by 34 weeks over 80 percent survived.[84]

The application of a prostaglandin gel to soften the cervix, followed by appropriately regulated doses of oxytocin and the rupturing of the membranes, would generally enable the live birth of an infant with a lethal abnormality after 33 weeks. Death would almost certainly be caused by the infant’s lethal defect, not prematurity. Since most infants begin to develop a coordinated ability to suck from 34 weeks there is normally a partial need for tube feeding up to this stage.

5.6 ETHICAL EVALUATION of ISSUES DURING PREGNANCY

Reasons in favor of abortion

Many women do not believe abortion is immoral, especially before they have become mothers themselves. To many abortion is a matter for each pregnant woman to decide, provided she understands what is involved. It is seen by some to be a matter of a woman’s autonomy to control her own body and fertility in relation to letting a pregnancy go to term unless she wants her baby. Abortion is perceived by some as an issue of women’s reproductive rights and no longer a remedy for rape or a matter of saving the mother’s life. Abortion is now seen by many to be a matter of women’s health, to be decided by women alone, not by society’s lawmakers, religious leaders, or doctors. Others who recognize women’s rights believe fetuses acquire rights once they become patients after viability, from which stage a woman’s right to abortion may be restricted.[85]

Granted the enormous impact these attitudes have had in western culture, it is easy to appreciate why women with unwanted pregnancies see few moral problems in having recourse to safe induced abortion. Research shows that of 30 primigravid women who wanted their pregnancies to go to term, most did not recognize their fetuses as persons early in the pregnancy and only referred to their fetus as their baby in the third trimester. In fact up to 8–12 weeks’ gestation, 70 percent did not believe the fetus was a real person. By 18–22 weeks’ gestation, after fetal movements had been felt, perceptions changed, and 63 percent said their fetus was a real person. By 36 weeks 92 percent believed the fetus was a person.[86]

I have already discussed in chapter 1 the view of philosophers who hold that a person could not be formed before the capacity for exercising minimal rational self-conscious acts is acquired. I also dealt with the ethical implications of this view in chapters 3 and 4, namely that a fetus would have no intrinsic value before sentience and no personal rights before birth. Christopher Belshaw argues along these lines in the context of the abortion debate.[87] For those who do not hold the fetus is a person, utilitarian criteria are used to justify abortion for health, personal, social, or economic reasons, provided a painless method is used. In this, they agree with Aristotle who permitted abortion for population control, but insisted it be done before a fetus was capable of sensation or of feeling pain.[88] Richard Hare believes abortion is prima facie and in general wrong because it stops a person coming into existence but that countervailing reasons could morally permit it.[89] Laura Purdy accepts women have duties, but not absolute moral duties, to care for their fetuses: “women’s rights might sometimes trump considerations about fetal welfare.”[90]

Mary Anne Warren argues for the right to abortion on the grounds it would be unreal to expect women to avoid sexual relations with men when pregnancy is not wanted, in view of the unreliability of contra­ceptives or the lack of access to them for some women.[91] She also dis­cusses whether the “personlikeness” of the fetus should be a sufficient basis to warrant moral respect be shown to the fetus. She dismisses this because the fetus lacks self-awareness and the capacity to reason or com­municate in a variety of ways. Because the fetus is less “personlike” than a mature mammal or the average fish, she concludes that the fetus would not “have any more right to life than, let us say, a newborn guppy.[92] And certainly, she says, this limited right to life is not greater than a woman’s right to abortion.

A case in defense of abortion is made by Judith Jarvis Thomson who, for the sake of argument, is prepared to grant that the fetus is a person.[93] She argues that a kidnapped woman would not be obliged to remain connected to a famous unconscious violinist with damaged kidneys who depended for survival on support from her kidneys for 9 months. She says a woman has rights over her own body in virtue of her autonomy as a person. She admits both are innocent and have a right to life. However, she argues that the woman would have no moral duty, if she had a choice, to remain kidnapped in hospital to save the famous vio­linist’s life, heroic and generous though such a gesture would be. The violinist would have no right to the lifesaving use of the woman’s body, even if only one hour were needed. She applies the same argument to the fetus in the uterus as a result of rape. The fetus would not have a right to remain in the woman’s uterus until birth and the woman would have no moral duty to carry the pregnancy to term. She admits a woman may have a duty out of decency to allow the fetus to remain in her uterus for a very short time to save its life, but this would not imply a strict right of the fetus to remain in the uterus. The general argument may be extended to the rights of a woman over her body in the case of a “mis­taken pregnancy” so that she would not be morally obliged to carry a pregnancy for nine months.

Thompson, in this case, made a judgment on the act in itself, regard-less of the consequences. Utilitarians would probably disagree and argue that the overall benefit in the case of the famous violinist, would tip the utilitarian scales in favor of the duty of the woman to remain connected to the violinist for 9 months to save their life. On the contrary, the utilitarian balance would probably not tip in favor of a fetus conceived as a result of rape.

Subsequently, Thompson developed her thinking and says her denial of a right to life for the fertilized egg or fetus is based on “the idea that having rights presupposes having interests.”[94] She admits, however, that she has “no conclusive reason for denying that fertilized eggs have a right to life.[95] But she denies that the doctrine for the right to life from conception can be known to be true by reason and asserts, “There is nothing unreasonable or irrational in believing that the doctrine is false” or “entirely without support.[96] She then argues her case that abortion should not be illegal “on a ground that neither reason nor the rest of morality requires women to accept . . . the reason for the constraint has to be one that the constrained are unreasonable in rejecting.”[97] As I said in chapter 1, this view is consistent for one who does not believe in an immaterial soul.

Reasons opposed to direct abortion

One needs the courage of King David and the wisdom of Solomon to embark on the moral evaluation of abortion. It is not a matter of judging the motives of a woman who has an abortion, but of giving an account of the morality of direct abortion based on respect for human life from conception.[98] Pope John Paul II taught direct abortion, namely,

abortion willed as an end or as a means, always constitutes a grave moral disorder since it is the deliberate killing of an innocent human being.[99]

The immorality of abortion is the same whether it is achieved by surgical or pharmacological means.

What underpins this teaching is the personal status of the fetus and embryo which has already been discussed in earlier chapters. The philosophical basis for according the fetus the status of a person is found in the rational nature of the human fetus whose life principle is an imma­terial soul which actuates the body, including the dynamism of the genetic code which directs organized growth and development at the empirical level. Human life is a basic good and a condition for the experience of values, including freedom, autonomy, and being a moral agent. A fetus is a subject of intrinsic worth and personal value before acquiring an ability to express rationally self-conscious acts. This stand is supported by a philosophical belief in God as Creator of an immaterial life principle as well as respect for fetal development.[100] It is anomalous that the value of the life of a fetus should depend on the choice of the mother and/or father. The fetus is defenseless and totally dependent on the mother for support and survival. Janet Podell, a former pro-choice feminist, changed her mind after having her first child:

It was impossible to ignore the plain fact that this baby was the same living being who had been kicking me in the ribs for months. His life was clearly an uninterruptible continuum that had begun long before I could feel him move _...[101]

Abortion deprives a real person, not merely a potential person, of life and of the opportunity to develop to the age of reason when free and morally responsible acts can be made.[102] One should always treat illness and alleviate the suffering of a pregnant woman but not by direct abortion, which is a breach of the duty of care owed to the fetus by the mother and doctors. It would be unethical to alleviate the trauma of a woman made pregnant by rape to choose induced or direct abortion as a means. In cases of an unwanted pregnancy it would be unethical, out of mis­guided compassion, to approve direct abortion or to materially cooper-ate at close hand to procure it. A pregnant woman’s right over her body does not include a right to deliberately terminate the life of a fetus. In cases of third trimester and late term abortions, the fetus is viable and capable of extrauterine life independently of the mother when given neonatal intensive care. This fact usually makes late term abortions morally repugnant even for those who are not opposed to early abortions.[103]

The taking of postcoital drugs with the purpose of preventing an embryo implanting in the uterus is the equivalent of a direct abortion. Hence these drugs are called abortifacients.[104] The primary purpose of the contraceptive methods considered above is the suppression of ovulation and/or the prevention of fertilization. These methods do not depend on an abortifacient effect to prevent pregnancy, even though rarely this may occur. Their use for contraceptive purposes would not be unethical from a pro-life perspective even if there is a very slight risk of preventing implantation as an unwanted side effect. Drug companies, even if not obliged by law, should include accurate information on the modes of action of contraceptive products in the customer information leaflet so that women may choose methods that do not involve any sig­nificant risk to possible early embryos.

The duty of reasonable care of a pregnant woman to her previable fetus does not preclude the performance of a medically necessary proce­dure whose object or immediate purpose is to save the pregnant woman from a life-threatening condition if it could not be delayed until the fetus was potentially viable outside the uterus. This would not be a direct abortion since the death of the fetus would be an unwanted and justi­fied side effect.[105] An example would be the necessary and lifesaving removal of a pregnant woman’s malignant cancerous uterus with its pre-viable fetus. In a case of ectopic pregnancy in the fallopian tube, it would be ethical to remove the pathological section enclosing a previable fetus or simply the chorionic villi and fetus, leaving the tube still functional, provided there is no direct harmful assault on the fetus.[106] When there is heavy bleeding caused by the placenta prematurely separating from the uterus it would not appeear to be a direct abortion nor unethical toinduce early labor to complete an irreversible miscarriage of a previable fetus to save the life of the mother instead of losing both mother and fetus. Likewise, in a rare case of severe very early onset pre­eclampsia/eclampsia, delivery of the placenta and previable fetus by induction of labor or caesarean section would not seem to be direct abor­tion if this was the only way to save the mother from imminent death due to multiple organ failure caused by a pathological placenta with abnormal trophoblastic invasion of the maternal arteries, including fetal DNA.[107]

In this book I have restricted my treatment of abortion to its ethical aspects. The termination of a pregnancy is a tragedy for both the pregnant women and her fetus. Abortion is not a good thing, but for many it is seen as a necessary evil. Most doctors would prefer to use their expertise and skills to save and not terminate life. It is difficult for an appreciation of the intrinsic value of human life at all stages to thrive in a pro-choice society. Humanity risks losing its moorings if a pregnancy is deemed a simple mistake to be erased at will.

Treatment of women who have been raped

 Women who have been raped are often immobilized by shock and need professional counseling to cope with the trauma caused by the assault. They need to be able to turn to a significant, trusted, and understanding person who will help them access immediate medical care from a doctor with the appropriate skills, including forensic training. Professional care minimizes the effect that the assault has on victims’ lives. Follow-up counseling would also be needed for the women, their families, and sup­portive friends.

Victims of rape need encouragement to report the crime to police and to freely consent to provide samples for DNA testing as forensic evidence of the attack so that rapists can be brought to justice.[108] An assessment needs to be made of their degree of psychological trauma, which is often severe, and they need to be given appropriate psychiatric or psychologi­cal therapy. An ethical response to rape cannot ignore the prolonged trauma experienced by these women, especially if pregnancy results. It is hard for people who have not been subjected to sexual assault and preg­nancy resulting from it to grasp the indignity suffered and the degree of personal pain inflicted and possibly life long brokenness yet to be endured.

Sexual offenses are crimes and should be denounced as such. The pres­ence of sperm in the woman’s reproductive tract represents an extension of the injustice of the original sexual assault if conception is possible. Since we are dealing with an act of violence it is ethically permissible to prevent conception after rape. The same applies if rape occurs within a marriage relationship because sexual intercourse without consent is not a marital act. However, from the perspective of the sanctity of human life, it would be unethical to deliberately prevent the implantation of an embryo which results from rape. It needs to be admitted, however, that some rape victims in their confusion and distress, may, in good faith, believe they are morally justified to prevent an embryo from implanting or to have an early abortion.

In rape cases, it would seldom be known with certainty whether ovulation had already occurred or was due to occur on the day of rape, because the assault might have happened on any day of the woman’s cycle. However, after a blood test she could be advised if the rape took place during her fertile period and whether it was possible for conception to have occurred on one of her seven fertile days, including the day after ovulation. For most of the cycle, then, ECPs would have no effect: they would not inhibit ovulation nor implantation.

In the light of the estimates given earlier, and assuming rape was the only instance of unprotected intercourse occurring randomly during a woman’s fertile period and the correct doses of EPCs (Yuzpe regimen) were taken, the actual number of pregnancies for 100 raped women would drop from the expected number of 15 to four. This would be due to the regimen’s 75 percent success rate, i.e. a 25 percent failure rate of four pregnancies – not an effective abortifacient at all. This means 11 expected pregnancies would have been prevented. It is unlikely that all of the failed pregnancies would be due to the prevention of implantation since it is known that EPCs suppress ovulation in 25 percent of cases if taken one or more days before the expected day of ovulation. Add to this that conception might be prevented by impeding sperm transport. Conservatively, one could assume that the risk to the life of an embryo would be about 8 percent or less. Indeed in the light of today’s knowl­edge of EPCs’ mode of action, it has been suggested their pregnancy failures may be more likely if ovulation and fertilization have already taken place at the time of treatment and, thus, prevention of implantation may not be one of the primary modes of action.[109]

It would seem to be ethically permissible to administer ECPs as soon as possible within 72 hours of rape to prevent conception if, after inquiry,there were no reasonable grounds to believe an embryo had been already conceived. In this case a risk of loss of an embryo due to the medication would not be more than about 8 percent, not disproportionate or sig­nificant after rape.[110] By the same token it would be ethical for an acci­dentally injured pregnant woman to have necessary, but not lifesaving, surgery, if it were to pose a similar risk to the life of her fetus. But an ECP could not ethically be taken if a test showed conception had, or most likely had, occurred. On ethical as well as medical grounds ECPs should not be used for family planning. But fear of their abuse does not negate their right use after rape. I agree with the US Catholic Bishops who said that a woman who has been raped may defend herself from conception from it and approved the following:

If, after appropriate testing, there is no evidence that conception has occurred already, she may be treated with medications that would prevent ovulation, sperm capacitation or fertilization.[111]

Early delivery of a fetus with anencephaly

Fetuses with anencephaly warrant special attention because of the serious ethical problems that their condition poses for pro-life parents and doctors. While some mothers are willing to allow these pregnancies to go to term, others find it too distressing once they know that their babies will inevitably die of their lethal abnormality soon after birth. The ques­tion arises whether the duty of reasonable care requires a pregnant woman whose fetus is affected by anencephaly to let her pregnancy go to term, or whether it is ethically permissible to induce early delivery once the diagnosis has been made. An ethical answer to this problem cannot ignore the above-mentioned facts relating to delivery of prema­ture normal and abnormal fetuses.

Granted the lack of scientific evidence mentioned above for a geneti­cally determined cause of anencephaly and in the light of the evidence of the proximate origin of anencephaly at 24–6 days after fertilization, this fetus should be accorded the status of a person from conception. It is difficult to deny that the infant with anencephaly who has a heart beat and can breathe spontaneously is a human individual. The individual’s brain formation began but is incomplete, resulting in an individual with a poorly functioning brain-stem and malformed, degenerated hemi­spheres. The fetus and infant with anencephaly is a human individual with a rational nature on account of a divinely created immaterial soul or life principle and who, due to a malformed cortex and brain damage, will never to able to express rational activities. We are not dealing with an individual who is “brainless,” “brain-absent,” or “brain-dead.” In the light of what has been said in chapter 4, no convincing philosophi­cal argument has been presented to warrant denying the status of a human individual and person to the fetus and infant with anencephaly.[112]

What an anencephalic pregnancy can cause to the fetal-maternal rela­tionship is relevant in ethical decision-making. As we have seen, labor and the delivery of these fetuses are difficult at term. Shoulder dystocia can cause the baby to become stuck in the birth canal, resulting in extreme trauma and a high risk of hemorrhage in the mother. A cae­sarean section is sometimes needed for the mother’s health. Due to the absence of the cranial vault, birth at term is often painful for the baby. Moral principles, however, require that a living human individual, no matter how deformed, be treated respectfully as a person until the contrary is proven beyond reasonable doubt.[113] As we have seen, in Australia in 1975 over two-thirds of fetuses with anencephaly died before birth, and of these about 30 percent died a few weeks before labor had commenced and about 70 percent during labor.

Fetuses with anencephaly will never be capable of long-term survival. They will never be able to actualize their potential to exercise rational and personal acts: their typically human development is complete. Main­taining such a pregnancy, it is said, merely “preserves limited physiologic growth.[114] On this basis an ethical case is made for early delivery once the diagnosis of anencephaly is confirmed with certainty from 16 weeks. It is argued that to relieve her distress the mother would be justified to withdraw her life-support of pregnancy by early induction and thereby allow her defective fetus to die of its inherent fatal condition soon after delivery. This early delivery need not be deemed a lethal act or direct abortion provided the fetus is not deliberately killed. The guiding analogy employed is that there is no ethical duty to provide treatment that is extraordinary, disproportionate, excessively burdensome, or even futile to sustain human life.

It is thought by those who support this opinion that it is different from direct abortion of a fetus whose death is caused by removal from the uterus because the fetus is too premature to survive outside the sup­portive environment of the uterus.[115] Long-term survival of an infantwith anencephaly outside the uterus is impossible on account of a defect that is incompatible with extrauterine life. Whether a fetus with anen­cephaly is delivered at 16, 24 or 40 weeks, death follows soon after birth. The extra weeks of uterine life would not be of any benefit to the fetus and would cause additional distress to the mother. This is not saying that the fetus has no value. It is saying that the prolonging of uterine life of a fetus with anencephaly would be of no value to the fetus. It seems too much for a mother to await the painful experience of labor at term, fol­lowed by the death of her child caused by a lethal pathology, not early delivery. It has also been suggested that early delivery could be equated with spontaneous abortion, the correcting of an error of nature, since most miscarried fetuses are grossly deformed.[116]

There is some appeal in the above line of reasoning and one could easily understand that some mothers in good faith would have recourse to early delivery at this stage. However, the reasons given are not convincing. Although pregnancy can be burdensome, it is a natural supportive envi­ronment for the fetus and cannot really be compared to an extraordi­nary artificial life-support system as though it were medical treatment to cure disease or some pathology. A lethally deformed fetus is still a living human individual and a person towards whom a duty of reasonable care is owed.

Granted we are dealing with fetuses with lethal anomalies, it would be futile to unduly prolong the dying process by employing NICU facil­ities after early delivery. The delivery of a normal fetus from 16–28 weeks’ gestation would per se be a lethal act since at that stage not even a healthy fetus could survive without NICU. Knowing that a fetus is afflicted with anencephaly does not ethically justify Feinberg’s position of terminating the life of a severely malformed fetus whose prospects for life after birth would be hopeless.[117] Justice and the duty of reasonable care rule out the deliberate termination of a pregnancy if the fetus would soon die of prematurity.

It is not convincing to argue that early delivery in these cases would be the ethical equivalent of imitating nature’s way of eliminating grossly deformed fetuses. The primary purpose of pregnancy is not to lose fetuses, but to enable a fetus to develop and grow to the stage of matu­rity required for survival without the life-support provided by the uterus. A 100 percent probability of some aged and seriously sick people dying naturally within a short space of time is no excuse for imitating nature to accelerate their encounter with death by euthanasia. The deliberate nontherapeutic early induction of a fetus with anencephaly, or even of a healthy fetus, before any normal fetus would be mature enough to survive outside the uterus without NICU would be ethically indistin­guishable from direct abortion. The fetus would die of prematurity as a direct result of early induction, not anencephaly.

Each case needs to be assessed for the good of both mother and fetus when making judgments that are both clinically and ethically correct in the light of the earlier discussion of the medical facts and the statistics on the natural death rates of fetuses with anencephaly before and during normal labor. There are limits to the duty of care owed by a pregnant woman to a fetus with a certain diagnosis of anencephaly. It is enough to bear in mind what has been said above regarding the hazards to the mother during labor at term if a fetus with anencephaly presents with a low brow and shoulder and the risk of a caesarean delivery. It seems unreasonable to require a pregnant woman to carry a pregnancy to term beyond the limits of the duty of reasonable care against her reasonable request, only to await the death of her child soon after birth. Births of normal fetuses are induced up to two weeks early for the health of the mother or for reasons of social convenience without any detriment to the health of the newborn infant.

It seems the moral respect due to a fetus with anencephaly who has no prospects of long-term survival could be ethically reconciled with a compassionate desire to alleviate her distress and minimize potential health risks for the mother. This could be done by inducing labor at a stage when a healthy fetus would have a reasonable chance of survival with fewer health risks for the mother. Bearing in mind that clinical assessments vary for each individual case, induction from 33 completed weeks would seem reasonable since normal infants have a two out of three chance of survival from 33 weeks without treatment in NICU. The mother could have the consolation of nursing her baby until natural death occurs due to the infant’s inherent lethal condition. This stage was deemed to be the threshold of viability prior to NICU. Henry Davis summed up the moral consensus of the 1950s as follows:

Expulsion of the fetus between the seventh and the ninth month is pre-mature birth or acceleration of birth, not abortion.[118]

In such cases the risk of death from immaturity would be absorbed by the greater risk of death caused by anencephaly itself soon after birth. In effect, the early induction of labor from about 33 completed weeks would almost certainly not expose infants with anencephaly to any new risk of death beyond that of their lethal defect, granted it would not be appropriate to place them in a NICU. By this stage the mother’s duty of reasonable care for her fetus would have been satisfied. The withdrawal of pregnancy support by early induction would not be direct abortion since the normal fetus would also have reasonable prospects of long-term survival at this stage.[119] Maternal distress is relieved by early induction of a fetus for whom continuing pregnancy would not be morally oblig­atory and who would die of a lethal defect, not prematurity.[120] It goes without saying that comfort and nursing care, including nutrition and hydration according to need and appropriate to the condition of the newborn, should always be provided. Even in the case of a late term induction of a fetus with a lethal defect, the cause of death would be the lethal defect, not induction.