Why abortion access matters even for people who want to be pregnant

October is Pregnancy Loss Awareness Month. So, I’d like to take the time to bring attention to a type of pregnancy loss that’s common but often left out of the discussion: desired pregnancies that are terminated through abortion.

A 2015 study by Priscilla Coleman noted that 4% of abortions occur in desired pregnancies — 4% out of the  ~619,591 abortions per year the CDC reported in 2018 (a number which in reality is likely higher given that reporting to the CDC is largely voluntary). That means an estimated 24,783+ abortions of desired pregnancies occurred in 2018. 

As an OB-GYN who’s been a part of the termination of hundreds of highly desired pregnancies throughout my career, I’ve seen how the excruciating grief and guilt some people experience is too often compounded by state and international abortion laws limiting the ability to receive this care. Laws that cause an increased burden and struggle for people who are already trying to navigate an emotionally, physically, and mentally difficult experience. Advocating for abortion access matters for these wanted pregnancies just as much as it does for unwanted ones.

Deciding to terminate a desired pregnancy

I often accompany patients through their journeys of termination after a high-risk obstetrician gives them an upsetting diagnosis and prognosis. These situations are extremely nuanced and delicate — and these decisions are never black and white, right or wrong. No one should ever be judged for their decisions, feelings, or how they process these experiences. 

I have seen people who’ve suffered years of infertility, finally got pregnant, and then learned that the fetus has an extra chromosome or an inherited condition. I have witnessed people who have come for their anatomy scan with their partners, excited to catch a glimpse of their future child — sometimes already feeling the flutters of life inside of them — to be told there are severe birth defects in the brain, heart, or spine and the fetus has a dismal prognosis. I’ve also been present when a birthing parent who previously had health conditions like diabetes, high blood pressure, heart disease, or autoimmune disease is told that even though it’s too early for the fetus to survive on its own, their condition has worsened to the point that continued pregnancy complications could put their own life at risk. I have witnessed pregnant people come in to be evaluated because they start to feel pressure, cramping, pain, or leakage of fluid and find out that their cervix has dilated, their bag of water has broken, or the labor process of an “abnormal” pregnancy has begun. All of these situations may lead to the heartbreaking decision to end the pregnancy for medical reasons. 

Some people who make this decision can’t bear the thought of birthing the baby — and want to be asleep and wake up when it’s over. Some need the experience of a vaginal birth and choose to labor and birth their baby. Whatever they choose can and should be supported.

Interestingly, a study in Australia demonstrated that even people who had previously viewed themselves as anti-abortion reevaluated their in-principle opposition if an abnormality was found in their pregnancy. But we should be supporting and showing compassion for all people’s reproductive choices. Whether they’re terminating an unwanted pregnancy or a highly desired pregnancy due to a medical condition, they’re making the right decision for themselves at that time.

Deciding to continue a desired pregnancy

Some people may decide to continue a pregnancy knowing that their child will not have a “normal” life — or that the odds are extremely poor that the fetus will even survive until birth. But that’s often only an option for people who can safely make it until periviability: the time when a fetus may possibly survive on the outside (the American College of Obstetricians and Gynecologists places this between 20 weeks and one day before 25 weeks). 

Sometimes the baby will be born breathing and with a heartbeat — maybe living for minutes, hours, or occasionally days. Some babies have already passed during labor. Sometimes the families can’t bear to look at a baby who doesn’t look like the one they envisioned when they’re born extremely premature with translucent skin, eyes fused shut, or severe anomalies that may be traumatic to see. Some want to hold their baby until they pass, and keep them in the room afterwards to honor them and grieve for them in the best way they know how. Families will always be offered comfort measures for babies who may survive on the outside for a prolonged period so they know they’re not suffering and in pain.

For others, the pregnancy may be too early and the risk too high to continue. If, for example, there’s no fluid around the fetus and the lungs don’t have the chance to develop, the pregnant person may show signs of infection and end up risking their uterine health and life if they stay pregnant. If the placenta starts to separate from the wall of the uterus (placental abruption) before a pregnancy is full-term, heavy bleeding may make it so the fetus doesn’t fully develop and possibly put the birthing parent’s life at risk. In cases like these, termination of pregnancy may be the safest intervention.

The complicated emotions involved

The grief suffered after pregnancy loss is a disenfranchised grief — one that society doesn’t always acknowledge, welcome, or discuss. This loss could come after past experiences related to pregnancy, making the person already nervous, scared, anxious, and more prepared for the possibility of further hardships and loss. Others are completely blindsided. Sometimes their friends, family, and coworkers won’t even have known they were pregnant and so life for everyone surrounding the grieving person continues as though nothing has happened. Their pregnancy, their baby, and their experience is not recognized or honored. It’s as if the pregnancy and possibility never existed, except to the birthing parent who carries that with them always. The grieving is done privately and often in isolation. 

This type of loss is, as explained by Christiane Manzella, PhD, senior psychologist and training instructor at the Seleni Institute, a “loss out of time”: the loss of someone loved and desired and fantasized about, yet someone who never even experienced life. Someone who the birthing parent was never able to get to know. The portrayal of pregnancy, childbearing, and motherhood that’s often in the media and presented by other people in society is a picture full of happiness, bliss, and ease — pregnancy is natural, birth is natural, we are meant to be parents, and once the positive pregnancy test comes back we just have to wait the nine months necessary before bringing home our perfect little bundles of joy. This myth is destroyed and we’re often left in shock and despair when something goes so tragically wrong.

But the loss of a desired pregnancy leads to more than just grief. It can also bring feelings of guilt, fear of judgment, and the added layers of mental health issues like trauma and postpartum depression.

Judgment from outside and within

People who’ve already told others about their pregnancy may go through the painful reality of figuring out how to explain the complexity of their loss. They may not even have the words to explain what happened — or decide to only share part of the story out of fear of judgment. Talking about the decision may be too traumatic and triggering, leading some people to avoid those with whom they’d previously been close. When they do tell others, people who do know about the loss might not acknowledge it at all. They may not offer words of kindness or compassion, or even ask how the grieving individual is feeling or how they can best support them.

Some people may feel like they’re choosing to end their child’s life even though they wouldn’t have survived, or they may have survived but had a life full of pain, health problems, and immense medical care needs. They may even have friends or family members who do not agree with their decision to terminate the pregnancy, or how they choose to grieve and honor the loss, and judge them — further exacerbating feelings of guilt and shame.

Abortion access can impact us all

After dealing with all of the above complexities and emotions, many pregnant people then face barriers to abortion care — making the tragedy, grief, and trauma of the loss of a desired pregnancy exponentially worse. In many parts of the world, including many states in the US, access to abortion is extremely restricted or outright banned — even in cases where the pregnancy is wanted but there are life-threatening abnormalities. 

The Center for Reproductive Rights has compiled and mapped out a thorough list of abortion laws by state. The most severe limitations, which were recently imposed in Texas, ban any abortion procedure after six weeks (when fetal cardiac activity can be detected). According to the Guttmacher Institute, other states aren’t far behind Texas. Many are currently fighting to ban abortions or severely restrict access so that it’s almost impossible for people, clinicians, and facilities to continue receiving and providing these services. These restrictions criminalize and impose undue physical, emotional, and psychological burdens on people seeking abortions — including those terminating highly desired pregnancies. Some risk people’s lives by forcing clinicians to ask for special permission before providing care, even when a person has severe medical complications, is septic, or is hemorrhaging. The time it takes to seek permission from committees or non-clinical legislators delays care and can cause increased maternal health risks or even death. 

We all deserve compassionate support

I am lucky to live and practice obstetrics and gynecology in a state that has expanded access to abortion care. A state where you don’t have to jump through hoops or receive special permission to terminate a pregnancy. A state where people with uteruses are supported and cared for in a safe and compassionate way.

As a women’s reproductive healthcare provider and advocate for reproductive justice and patient-centered holistic healthcare, I believe we all need to fight for bodily autonomy, access to abortion care (as well as contraception), and all other aspects of our reproductive health and overall well-being. We also need to support and embrace all of the people who are currently suffering or will suffer a pregnancy loss silently and alone. Please join me and Hey Jane in our mission to increase awareness, knowledge, and compassionate support around pregnancy loss and abortion care.

If you’ve experienced a pregnancy loss and are looking for resources for support, check these out:

• Share Pregnancy and Infant Loss Support
• Seleni Institute
• Star Legacy Foundation

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