Intact dilation and extraction

Intact dilation and extraction (IDX or intact D&X), also known as intact dilation and evacuation (intact D&E), dilation and extraction (D&X), intrauterine cranial decompression and controversially in the United States as partial birth abortion, is a surgical abortion wherein an intact fetus is removed from the womb via the cervix. The procedure may also be used to remove a deceased fetus that is developed enough to require dilation of the cervix for its extraction.

Though the procedure has had a low rate of usage, representing 0.17% (2,232 of 1,313,000) of all abortions in the United States in 2000 according to voluntary responses to an Alan Guttmacher Institute survey, it has developed into a focal point of the abortion debate. In the United States, intact dilation and extraction was made illegal under some circumstances by the Partial-Birth Abortion Ban Act, which the U.S Supreme Court upheld in the case of Gonzales v. Carhart.

Etymology
The term dilation and extraction, or D&amp;X, was coined by Cincinnati physician W. Martin Haskell, MD in a monograph that was distributed by the National Abortion Federation in September of 1992. Haskell's term was a variation on intact dilation and evacuation (shortened to intact D&amp;E), the term preferred by Dr. James McMahon, who developed the procedure in 1983 as an alternative to dilation and evacuation or D&amp;E.

The American College of Obstetricians and Gynecologists (ACOG) has settled on the term intact dilation and evacuation (intact D&E) for this procedure. The much smaller American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) contends that this was a contrived attempt by ACOG to legitimize the abortion technique in question, by wedding it to "D&E" (a long-recognized procedure) using a sort of legitimacy by association. The American Medical Association (AMA) has settled on the term intact dilation and extraction (intact D&X) for this procedure.

Intact D&X surgery
According to the American Medical Association, this procedure has four main elements. First, the cervix is dilated. Second, the fetus is positioned for a footling breech. Third, the fetus is extracted except for the head. Fourth, the brain of the fetus is evacuated so that a dead but otherwise intact fetus is delivered via the vagina.

Usually, preliminary procedures are performed over a period of two to three days, to gradually dilate the cervix using laminaria tents (sticks of seaweed which absorb fluid and swell). Sometimes drugs such as synthetic pitocin are used to induce labor. Once the cervix is sufficiently dilated, the doctor uses an ultrasound and forceps to grasp the fetus' leg. The fetus is turned to a breech position, if necessary, and the doctor pulls one or both legs out of the birth canal, causing what is referred to by some people as the 'partial birth' of the fetus. The doctor subsequently extracts the rest of the fetus, usually without the aid of forceps, leaving only the head still inside the birth canal. An incision is made at the base of the skull, scissors are inserted into the incision and opened to widen the opening, and then a suction catheter is inserted into the opening. The brain is suctioned out, which causes the skull to collapse and allows the fetus to pass more easily through the birth canal. The placenta is removed and the uterine wall is vacuum aspirated using a suction curette.

Circumstances and reasons for this procedure
IDX, along with dilation and evacuation (D&E), early induction of labor, and rare procedures such as saline abortion, are only used in the late stages of pregnancy. Late-term abortions at 21 weeks or later account for 1.4% of all abortions in the USA. Intact D&amp;X procedures are used in approximately 15% of those late-term abortion cases. This is the equivalent of between 2,500 and 3,000 per year, using data from the Alan Guttmacher Institute for the year 2000. They are typically performed between the twentieth and twenty-fourth week of pregnancy.

Women choose to have late-term abortions for a variety of reasons. Once a pregnant woman has made the decision to have a late-term abortion, she or a doctor may choose IDX over other available late-term abortion procedures because:
 * Although a woman may experience contractions, she does not have to experience labor.
 * IDX is an outpatient procedure; the woman does not have to be hospitalized.
 * The woman does not have to undergo abdominal surgery.
 * The procedure results in a largely intact body over which the parents may grieve.
 * Instruments are inserted into the uterus fewer times than in a D&amp;E abortion, potentially reducing the risk of uterine tearing.
 * The fetus may have hydrocephalus, where the head may expand to a radius of up to 250% of a normal skull at birth, making it impossible for it to pass through the cervix. If live birth is desired, the physician may drain the excess fluid in utero using a syringe, or a caesarian section may be done as soon as amniocentesis indicates lung maturity. If abortion is desired, D&amp;X may be the simplest procedure.

Reasons a woman or physician may not choose IDX, opting instead for another abortion procedure, include:
 * IDX requires a larger dilation of the cervix than D&amp;E.
 * Podalic version (turning the fetus into a breech position) can be dangerous to the woman.
 * The incision in the fetal skull is made blind; the physician may miss and injure the woman's cervix.

"Partial-birth abortion"
The term "partial-birth abortion" is primarily used in political discourse — chiefly regarding the legality of abortion in the United States. This term was first suggested in 1995 by pro-life congressman Charles T. Canady, while developing the original proposed Partial-Birth Abortion Ban. Keri Folmar, the lawyer responsible for the bill's language, says the term developed in early 1995 in a meeting between her, Charles T. Canady, and National Right to Life Committee lobbyist Douglas Johnson. Canady could not find this particular abortion practice named in any medical textbook, and therefore he and his aides named it. "Partial-birth abortion" was first used in the media on 4 June 1995 in a Washington Times article covering the bill.



In the U.S., a federal statute defines "partial-birth abortion" as any abortion in which the fetus is extracted "past the navel [of the fetus] . . . outside the body of the mother," or "in the case of head-first presentation, the entire fetal head is outside the body of the mother," in order to cause death of the fetus. The U.S. Supreme Court has held that the terms "partial-birth abortion" and "intact dilation and extraction" are basically synonymous. However, there are cases where these overlapping terms do not coincide. For example, the IDX procedure may be used to remove a deceased fetus (e.g. due to a miscarriage or feticide) that is developed enough to require dilation of the cervix for its extraction. Removing a dead fetus does not meet the federal legal definition of "partial-birth abortion," which specifies that partial live delivery must precede "the overt act, other than completion of delivery, that kills the partially delivered living fetus." Additionally, a doctor may extract a fetus past the navel and then "disarticulate at the neck", which could fall within the terms of the statute even though it would not result in an intact body and therefore would not be an intact dilation and extraction.

In addition to the federal ban, there have also been a number of state partial-birth abortion bans. There, courts have found that state legislation (rather than federal legislation) intended to ban "partial-birth abortions" could be interpreted to apply to some non-intact dilation and evacuation (D&E) procedures. Though sometimes performed during the same developmental stage wherein most IDX procedures are done, non-intact D&E is a separate procedure.

There is debate over use of the term "partial-birth abortion". Those who oppose the term consider it a political term used to frame the argument in a way which is favorable to those who seek greater legal restrictions, or a total ban, on this or all abortion procedures, and have called the alleged political framing "partial truth abortion".

Controversy
IDX is a target of pro-life advocates who believe the procedure illustrates their contention that abortion, and especially late-term abortion, is immoral. Critics consider the procedure tantamount to infanticide, or murder, a position which many in the pro-life movement extend to cover all abortions. Some advocates, both for and against abortion rights, see the IDX issue as a central battleground in the wider abortion debate, representing an attempt to set a legal precedent so as to gradually erode access to all abortion methods.

Dr. Martin Haskell has called the IDX procedure "a quick, surgical outpatient method" for late second-trimester and early third-trimester abortions. The Partial-Birth Abortion Ban Act of 2003 describes it as "a gruesome and inhumane procedure that is never medically necessary."

According to a BBC report about the U.S. Supreme Court's decision in Gonzales v. Carhart, "government lawyers and others who favour the ban, have said there are alternative and more widely used procedures that are still legal - which involves dismembering the foetus in the uterus." An article in Harper's magazine stated that, "Defending the Partial-Birth Abortion Ban... requires arguing to judges that pulling a fetus from a woman's body in dismembered pieces is legal, medically acceptable, and safe; but that pulling a fetus out intact, so that if the woman wishes the fetus can be wrapped in a blanket and handed to her, is appropriately punishable by a fine, or up to two years' imprisonment, or both." The U.S. Supreme Court has stated that intact D&X remains legal as long as there is first an "injection that kills the fetus."

There is also controversy about why this procedure is used. Although prominent defenders of the method asserted during 1995 and 1996 that it was used only or mostly in acute medical circumstances, Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers (a trade association of abortion providers), told the New York Times (Feb. 26, 1997): "In the vast majority of cases, the procedure is performed on a healthy mother with a healthy fetus that is 20 weeks or more along." Some prominent self-described pro-choice advocates quickly defended the accuracy of Fitzsimmons' statements.

In support of the Partial-Birth Abortion Ban Act, a nurse who witnessed three IDX procedures found them deeply disturbing, and described one performed on a 26½-week fetus with Down Syndrome in testimony before a Judiciary subcommittee of the US House of Representatives:

""Dr. Haskell went in with forceps and grabbed the baby’s legs and pulled them down into the birth canal. Then he delivered the baby’s body and the arms, everything but the head. The doctor kept the head right inside the uterus....The baby’s little fingers were clasping and unclasping, and his little feet were kicking. Then the doctor stuck the scissors in the back of his head, and the baby’s arms jerked out, like a startle reaction, like a flinch, like a baby does when he thinks he is going to fall. The doctor opened up the scissors, stuck a high-powered suction tube into the opening, and sucked the baby’s brains out. Now the baby went completely limp....""

A journalist observed three IDX and two D&E procedures involving fetuses ranging from 19 to 23 weeks. She "watched for any signs of fetal distress, but ... [she] could see no response, no reflexive spasm, nothing. Whether this was a result of the anesthesia or an undeveloped fetal system for pain sensitivity, one thing was clear: There was no discernable response by the fetus."

Abortion provider Warren Hern asserted in 2003 that "No peer-reviewed articles or case reports have ever been published describing anything such as 'partial-birth' abortion, 'Intact D&E' (for 'dilation and extraction'), or any of its synonyms." Therefore, Hern expressed uncertainty about what all of these terms mean. The U.S. Supreme Court held in Gonzales v. Carhart that these terms of the federal statute are not vague.

Federal law
Since 1995, led by Congressional Republicans, the United States House of Representatives and U.S. Senate have moved several times to pass measures banning the procedure. Congress passed two such measures by wide margins during Bill Clinton's presidency, but Clinton vetoed those bills in April 1996 and October 1997 on the grounds that they did not include health exceptions. Subsequent Congressional attempts at overriding the veto were unsuccessful. Doctors "have been successfully sued for failure to refer patients for late-term abortions in cases of fetal abnormalities."

A major part of the legal battle over banning the procedure relates to health exceptions, which would permit the procedure in special circumstances. The 1973 Supreme Court decision Roe v. Wade, which declared many state-level abortion restrictions unconstitutional, allowed states to ban abortions of post-viable fetuses unless an abortion was "necessary to preserve the life or health of the mother." The companion ruling, Doe v. Bolton, upheld against a vagueness challenge a state law that defined health to include mental as well as physical health. The Court has never explicitly held, as a matter of constitutional law, that states have to allow abortions of post-viable fetuses if doing so is necessary for the mother's mental health, but many read Doe as implying as much. The concern that the health exception can be read so liberally partly explains why supporters of the Partial-Birth Abortion Ban Act did not want to include one.

The Act includes an exception for the life of the woman, but explicitly not for non-life-threatening health issues; opponents believe that this exception is too narrow and have mounted numerous legal challenges. Congress asserted that the procedure is never necessary for maternal health.

In 2003, the Partial-Birth Abortion Ban Act (HR 760, S 3) was signed into law; the House passed it on October 2 with a vote of 281-142, the Senate passed it on October 21 with a vote of 64-34, and President George W. Bush signed it into law on November 5.

Beginning in early 2004, the Planned Parenthood Federation of America, the National Abortion Federation, and abortion doctors in Nebraska challenged the ban in United States District Courts in San Francisco, New York, and Lincoln, Nebraska, respectively. All three District Courts ruled the ban unconstitutional that same year, and their respective appellate courts (Ninth, Second, and Eighth) affirmed these rulings on appeal.

The three cases were all appealed to the Supreme Court of the United States, and were consolidated into the case Gonzales v. Carhart. On April 18, 2007, the Supreme Court voted to uphold the Partial-Birth Abortion Ban Act by a decision of 5-4. Justice Kennedy wrote for the majority and was joined by Justices Thomas, Scalia, Alito, and Chief Justice Roberts. A dissenting opinion was written by Justice Ginsburg and joined by Justices Stevens, Souter and Breyer.

State law
Many states have bans on late-term abortions which apply to the IDX procedure if it is performed after viability.

Many states have also passed bans specifically on the IDX procedure. The first was Ohio, which in 1995 enacted a law that referred to the procedure as dilation and extraction. In 1997, the United States Court of Appeals for the Sixth Circuit found the law unconstitutional on the grounds that it placed a substantial and unconstitutional obstacle in the path of women seeking pre-viability abortions in the second trimester.

Between 1995 and 2000, 28 more states passed Partial-Birth Abortion bans, all similar to the proposed federal bans and all lacking an exemption for the health of the woman. Many of these state laws faced legal challenges, with Nebraska's the first to reach decision in Stenberg v. Carhart. The Federal District Court held Nebraska's statute unconstitutional on two counts. One being the bill's language was too broad, potentially rendering a range of abortion procedures illegal, and thus, creating an undue burden on a woman's ability to choose. The other count was the bill failed to provide a necessary exception for the health of the woman. The decision was appealed to and affirmed by both the Eighth Circuit and the Supreme Court on June 2000, thus resolving the legal challenges to similar state bans nationwide.

Since the Stenberg v. Carhart decision, Virginia, Michigan, and Utah have introduced laws that remain virtually identical to the unconstitutional Nebraska law. The Virginia and Michigan laws were similarly struck down due to broadness and the failure to provide a health exemption, Utah's law remains pending trial, though is unenforceable due to a court-issued preliminary injunction.

In 2000 Ohio introduced another "partial-birth abortion" ban. The law differed from previous attempts at the ban in that it specifically excluded D&amp;E procedures, while also providing a narrow health exception. This law was upheld on appeal to the Sixth Circuit in 2003 on the grounds that "it permitted the partial birth procedure when necessary to prevent significant health risks."

In 2003 the Michigan Senate introduced Senate Bill No. 395. The bill, which would change the legal definition of birth, would in effect ban partial birth abortions. The definition of birth as defined in the bill was that once any part of the body had passed beyond the vaginal plane of introitus it is considered a birth. The bill included an exemption for the mother's health. The bill was passed by both the Senate and House of Representatives but was vetoed by governor Jennifer Granholm.

Legal and political situation in the United Kingdom
Questioned about UK government policy on the issue in Parliament, Baroness Andrews stated that "We are not aware of the procedure referred to as 'partial-birth abortion' being used in Great Britain. It is the Royal College of Obstetricians and Gynaecologists' (RCOG) belief that this method of abortion is never used as a primary or pro-active technique and is only ever likely to be performed in unforeseen circumstances in order to reduce maternal mortality or severe morbidity."

Legislation, testimony, and court decisions

 * Appeals court upholds Ohio "partial-birth abortion" law (AMANews article) : 19 January 2004.
 * Appeals Court decision in Haskell v. Taft, upholding Ohio PBA Ban : (decided 17 December 2003) Includes description of the procedure, Decision of the Court, and Dissenting opinion
 * Partial Birth Abortion Ban Act of 2003, signed by President Bush in March, 2003
 * Ohio law banning "partial birth feticide" : enacted 18 August 2000.
 * Stenberg v. Carhart Decision voiding Nebraska's PBA ban, circa 2000
 * HR 1833, vetoed by President Clinton in 1996
 * Congressional Testimony of Brenda Pratt Shafer, RN, March 21, 1996

Commentary

 * Ban Wagons - Reason Magazine article about the naming of "partial birth abortion" (supporting legality of the procedure)
 * About.com's Pros & Cons of Partial Birth Abortion (neutral about the legality of the procedure)
 * The Myth of Partial Birth Abortion, by Don Sloan, MD (supporting the legality of the procedure)
 * Partial-Birth Abortion - A Chink In The Pro-Abortion Armor (opposing the legality of the procedure)
 * The "Partial-Birth" Myth - No, it's not a birth (supporting the legality of the procedure)
 * Gina Gonzales as told to Barry Yeoman, "I Had An Abortion When I Was Six Months Pregnant," Glamour (supporting the legality of the procedure)

Other

 * Martin Haskell's 1992 monograph, which called the procedure "Dilation and Extraction"
 * ReligiousTolerance.org: D&X Procedure (aka Partial Birth Abortion) - All sides
 * Presbyterians pro-life: A Pediatrician Looks at Babies Late in Pregnancy and Late Term Abortion
 * A doctor's right to choose - Salon.com article