Introduction

Late abortions (after 24 weeks gestational age) are extreme by any national and international comparison. Just seven of the 50 States in the US permit unrestricted abortion after 24 weeks.1 Internationally, only five of the 198 countries, independent states, and semi-autonomous regions with populations exceeding 1 million permit abortion after 24 weeks.2 Three of the five nations that permit late abortion are notorious human rights abusers: China, North Korea, and Vietnam. Colorado should not aspire to join the ranks of the few states and countries that dehumanize the late term fetus and permit the killing of these most vulnerable human beings. Colorado should also not jeopardize the health of Colorado women by allowing the unregulated out-patient practice of late abortion which is known to pose serious risks to the health and life of the woman.3

Late abortion is predicated on the notion that a woman’s right to bodily autonomy trumps the fetus’ right to life. Both prolife and prochoice advocates would agree that a woman’s autonomy is an extremely important value; however, both sides differ on whether autonomy supersedes another human being’s fundamental right to life. These competing rights are why proponents of access to late abortion go to extreme lengths to minimize the humanity of the fetus. They refer to “terminating the pregnancy” as if the termination could occur without killing a vital, developing human being. Orwellian language is utilized to refer to the crushed and dismembered fetus as “products of conception” or simply “POC”. A recent series on abortion rights by the Editorial Board of The New York Times refers to the developing human merely as a “cluster of cells” as if her brain, heart, circulatory system, appendages, hands/feet and nervous system were immaterial.3 Even the preferred term “fetus” is an attempt to dehumanize the developing human. OB-GYN physicians commonly refer to the “baby” during a woman’s wanted pregnancy, but abortionists will rarely refer to the “fetus”, much less use the term “baby”, when counseling a woman on abortion.

There is little doubt that there is a bipartisan consensus that late abortions should be regulated. According to a 2018 Gallup poll, only 18% of Democrats, 13% of Independents, and 6% of Republicans believe that third trimester abortions should be legal.5 The polling presumably reflects the public’s widespread recognition that late abortion kills a human being not materially different than a newborn infant and that late abortion represents a substantial medical risk to the pregnant woman.

Is the 24 week fetus a human being?

Human embryology has long attested to the fact that human life begins at fertilization and that human development is a seamless, continuous process that continues for years past birth. A primordial heart develops in the human embryo by the third week (post fertilization) and begins to pump blood by the fourth week.6 Rapid development of the brain occurs in the fifth week. By the eighth week, the embryo has distinctly human characteristics, developed the beginnings of all major organ systems, and demonstrates purposeful limb movements. During the 17th week, the mother can feel the fetal movements.

Fetal surgeries, in which the fetus is operated on by specially trained fetal surgeons and anesthesiologists, have been pursued as early as the 19th- week gestation (post last menstrual period).7-8 Fetuses have been born in the 21st-week gestation with excellent neurodevelopmental outcomes.9 Based on studies performed on infants born at 24 weeks gestation between 2004 and 2011, 58-77% survive with active treatment.10-11

While there is considerable debate concerning when the fetus can experience pain, it is very likely that a 24-week-old fetus can experience pain – perhaps more intensely than an infant or adult. Some researchers argue that a functional mesodiencephalon is all that is required and that a fetus as young as 15 weeks gestation can perceive pain.12 Because inhibitory descending serotonin pathways in the nociceptive system mature only after birth, the fetus might be even more sensitive to pain than infants or adults. Other researchers insist that functional thalamocortical circuitry is required for conscious perception of pain.13 However, even for these latter researchers, there is good evidence that the thalamic pain fibers reach the cortex on or near the 24th week. Thalamic projections reach the visual subplate at 20-22 weeks, the visual cortex at 23-27 weeks, and the auditory cortical plate at 24-28 weeks.13-14 Given these findings, it should be assumed that the 24-week-old fetus could feel pain.

Besides neuroanatomy, there are other observations that support the notion that a fetus can experience pain. As early as 18 weeks gestation the fetus exhibits pituitary-adrenal, sympathoadrenal, and circulatory stress responses to noxious stimuli.14 Even more provocative is the observation from 4-D ultrasounds that fetuses as young as 24 weeks exhibit facial expressions consistent with pain or distress.15-16 Furthermore, preterm infants at the lowest limit of viability have “profound, acute adverse reactions” to major painful stimuli.17

Late second trimester and third trimester fetuses display a number of other advanced cortical functions. The fetus’ sensorimotor behavior demonstrates the same characteristics later observed in the child’s behavior.18 They show curiosity or intrinsic motivation to explore their body and environment, perform repetitive actions to elicit sensations, react to sensory inputs, display intentionality, and demonstrate goal directed movements.18 It has also long been recognized that the fetus can respond to sound as early as 19 weeks.19 The fetus specifically responds to her/his mother’s voice. At 25 weeks fetuses have been observed to mimic their mother’s resuscitation of a nursery rhyme by opening and closing their mouths.18 Furthermore, a newborn human shows preference for her/his mother’s voice and for musical pieces to which she/he were previously exposed, which confirms a capacity for a fetus to learn in utero.20 Studies have shown that prenatally acquired acoustical memory can persist at least as long as 6 weeks.21

Fetuses in utero with gestational ages of 24 weeks or greater are biologically indistinguishable from infants born at 24 weeks. They have developed all the essential organ systems, they can perceive pain, they can demonstrate sophisticated behaviors, they can respond to and learn from familiar sounds, and they can undergo curative operative therapies as independent patients. The only difference is location. Location should not be the determinant of human value. A human’s inalienable right to life, proclaimed in our Declaration of Independence, has not, and should not be, contingent on location.

Who chooses late abortion and how common is the practice?

There is very limited information available in the United States regarding who pursues very late abortions. Most studies suggest women have late abortions for similar reasons that they have early abortions with several caveats.22-24 Age and educational level were not associated with abortions after 16 weeks but black women and women with higher incomes were more likely to have late abortions in one Guttmacher sponsored study.22 Another study which was based on the baseline Turnaway data concluded that “among women without fetal anomalies, reasons for seeking abortion are not different whether women sought abortion early or late in pregnancy.”23 They did not find a statistically significant difference between early and late second trimester abortions based on finances, parity, timing of pregnancy, degree of interference with future opportunities, emotional/mental preparedness, health related reasons, prospects for the baby, level of independence/maturity, influences from family/friends or the inability to contemplate adoption. A second study based on the Turnaway data suggested statistically significant differences in the age of the woman (younger patients, later abortions OR 2.7) and time that pregnancy was recognized (before 8 weeks, earlier abortions OR 0.1).24 They also found that women who had late abortions faced more logistical delays (finding a provider, raising funds, and travel costs). Both Turnaway studies excluded abortions for fetal anomalies or life endangerment.

Many people are under the impression that most late term abortions are necessitated by terrible fetal anomalies or life endangering conditions. Hillary Clinton famously made this assertion during a debate with candidate Donald Trump. This assertion was widely debunked by fact checkers.24-25 Diana Foster, Professor at the University of California San Francisco’s Bixby Center for Global Reproductive Health stated that “there aren’t good data on how often later abortions are for medical reasons”. Her opinion, based on the limited research and discussions with fellow researchers in the field, was that abortion for fetal anomalies “make up a small minority of later abortions”.25 There are other sources including investigations, blog posts, interviews and documentaries that suggest it is not hard to schedule a late abortion or uncommon to abort an entirely normal fetus after 24 weeks gestation.26-29 In Colorado, the Boulder Abortion Clinic advertises elective abortions (for any reason) to 26 weeks and then to 36 weeks for “medically indicated terminations”.30 (Anecdotal evidence suggests that the Boulder Abortion Clinic is willing to consider later abortions for normal fetuses).26,29,31 For those women who do have fetuses with likely life-limiting genetic or congenital abnormalities, perinatal hospice offers a holistic, humane, and compassionate alternative to late abortion.32

There is no mandatory reporting for abortion numbers, indications or complications in the United States. Consequently, it is difficult to objectively assess the practices of late term abortionists and the patients they serve. It is also uncommon for an independent expert to review late abortionists’ practices. In a rare move that resulted in significant controversy/litigation, Kansas Attorney General Phil Kline had Dr. Paul McHugh, University Distinguished Service Professor of Psychiatry at Johns Hopkins School of Medicine, review redacted records of prominent third-trimester abortionist, George Tiller. Dr. McHugh reported that he found instances where abortions were obtained for “trivial reasons” (like a desire to play sports) and for psychiatric reasons (such as adjustment disorder, anxiety, and depression) that could have been more appropriately remedied without resorting to late abortion.33

To obtain Colorado-specific abortion data is extremely difficult. The Colorado Department of Health collects an (admittedly) incomplete survey of abortion providers (since it is not mandatory and there is no enforcement mechanism). In their 2017 Report of Induced Terminations of Pregnancy, 285 abortions were performed after 21 weeks gestation in Colorado.34 The Guttmacher Institute pegs the rate approximately 24% higher (based on previous data).35 Assuming the CDPHE underestimation is uniformly distributed amongst all gestational ages, this would translate into approximately 353 abortions after 21 weeks in the last reporting year.

Few Colorado abortionists admit performing late/third trimester abortions. The exception is Dr. Warren Hern from the Boulder Abortion Clinic. In a number of newspaper and magazine stories, the impression is given that he only performs late abortions for fatal fetal anomalies and life-endangering conditions of the mother.36-37 However, Dr. Hern has admitted that 70% of his abortion practice is for normal fetuses.38 In those 30% of abortions performed for fetal anomaly, he reports that Down Syndrome is his most common indication (24%). Potentially treatable structural anomalies are included in his series (such as spina bifida, aortic stenosis, abdominal wall abnormalities, urinary obstruction, extra digits, fused digits, deformed hands or feet, scoliosis, and cleft lip/palate).38

How often is it medically necessary to abort a fetus to preserve the life or health of the mother? Dr. Diane Foster from the University of California San Francisco states that the number is very hard to characterize.25 Although there is almost no literature on the subject, one Maternal-Fetal Medicine expert concludes that this is an exceedingly rare event, perhaps encompassing as few as 4 extremely uncommon conditions: pulmonary hypertension (primary or Eisenmenger’s syndrome), Marfan’s syndrome with aortic root involvement, complicated coarctation of the aorta, and peripartum cardiomyopathy with residual dysfunction.39 These would all likely be adjudicated long before 24 weeks gestation. Dr. Hern has said that he is unaware of a situation where abortion was necessary (as opposed to delivery) to save the life of a mother in the third trimester.40

Late abortions are performed for the same reasons that early abortions are performed. There may be more abortions for fetal anomalies late in pregnancy, but this is still likely a small proportion overall. Late abortions occur commonly in Colorado, but figures are inaccurate and lack some demographic and medical detail. Abortions to preserve the life of the mother are a very rarely, if ever, indicated in late abortion. Perinatal hospice offers an alternative to late abortion for families confronting a fetus with a likely terminal diagnosis.32

How are late abortions performed?

There are many different abortion techniques and remarkable procedure variability among physicians performing late second trimester and third trimester abortions. This reflects the lack of consensus in the abortion community.

Generally, beginning at 16 weeks gestation, Dilation and Evacuation (D&E) replaces sharp curettage and suction curettage as the surgical abortion procedure of choice.41 During D&E, cervical dilation is achieved over one or more days by osmotic dilators and misoprostol to facilitate the subsequent mechanical destruction and dismemberment of the fetus. Parts of the fetus grasped/torn from her/his torso are then easily removed through the dilated cervix. A large-bore vacuum curette is used to remove the placenta and remaining tissue. Administration of a pre-procedure feticide such as intraamniotic/intrafetal digoxin, intracardiac potassium chloride or transection of the umbilical cord sometimes proceeds the D&E.

Dilation and Extraction (D&X) is similar to the D&E procedure except that a suction cannula is utilized to evacuate the brain after delivery of the fetal body/legs through the dilated cervix.40 The ensuing collapse of the head facilitates its passage through the cervical canal. In the popular vernacular this procedure is referred to as “Partial-Birth Abortion”. In order to comply with the Partial-Birth Abortion Ban Act of 2003, fetal demise must be ensured prior to the procedure. This is accomplished using a pre-procedure feticide or by transection of the umbilical cord.

During an Induction Abortion, labor is induced using mechanical means and/or by chemical means .40 The fetus is then delivered intact. To remain within the framework of the law, fetal demise is achieved prior to delivery using a feticide.

Abortion proponents make the claim that fetal death during abortion is more compassionate and painless than natural fetal/infant death in instances where the fetus has a terminal diagnosis. However, there are no published studies comparing the pain/suffering induced during abortion vs. natural fetal/infant death.

During D&E, there are estimates that only one half of fetuses are killed prior to the dismemberment procedure.42-43 It is hard to imagine that dismemberment would be less painful than natural death in conjunction with advanced perinatal hospice/palliative care services.

Even for those fetuses who are killed before they are dismembered or delivered, there could be substantial suffering. A highly concentrated potassium infusion can cause intense intravascular burning in normal patients.44 Even though an intracardiac infusion of potassium can kill a fetus within 2 minutes, It’s impossible to ascertain whether the fetus experiences intense pain prior to its demise.45 Intraamniotic or intrafetal digoxin is the more commonly used poison to achieve fetal demise.46 A digoxin overdose in older humans causes intense nausea, vomiting, abdominal pain, visual disturbances and delirium.47-49 Digoxin kills by causing severe bradycardia culminating in asystole, but it does not kill quickly. It can take up to 4 hours for intrafetal and up to 24 hours for intraamniotic digoxin to achieve asystole.50-51 Women are routinely told to anticipate “kicks” for hours after the feticide is administered.52 The visual, gastrointestinal, neurological and cardiac manifestations of digoxin toxicity could arguably represent fetal cruelty. Indeed, if this same methodology was utilized in a death penalty case, it would be considered “cruel and unusual punishment”.

In more candid moments, even abortion advocates sometimes characterize late abortion procedures on fetuses as “morally abhorrent”.53 It is a form of intimate human violence which is unparalleled in medicine. The only reason that it persists is that the violence is hidden within the confines of the uterus. When the mother (and the broader public) are shielded from the reality of the carnage that is being inflicted on the fetus, it is easier to rationalize its utility. Since there are no studies on the pain associated with late fetal abortion, to regard this as a painless, humane procedure is either wishful thinking or horribly misguided.

What is the risk to the woman undergoing a late abortion?

Late abortion is associated with significant morbidity and mortality. The precise magnitude of the risk associated with abortion can’t be reliably gleaned from the CDC or state databases because reporting abortion numbers and related complications is not consistently state mandated and never federally mandated. Furthermore, abortion procedures in the US are not linked to other sources of health data such as birth or death certificates making meaningful estimates of mortality rates nearly impossible. Since the system is voluntary and physicians are reluctant to disclose serious complications (including death), underreporting is also a major problem.54 There have been multiple instances documented where abortion related deaths were not captured by the official state/federal databases.54

Even using the admittedly inadequate medical claims/surveillance data, late abortion poses a substantial risk compared to early abortion in both relative and absolute terms. Using California Medicaid billing data, Emergency Department visits and complications were 2.5 times more likely following a second trimester abortion compared to a first trimester abortion.55 Data from the national Abortion Surveillance System indicate that while the overall risk of death from abortion was 0.7/100000 induced abortions, the risk of death increased exponentially (by 38%) for each additional week of gestation.56 CDC researchers found that gestational age was the strongest predictor of abortion-related-mortality.3 In absolute terms, the risk goes from 0.1 deaths/100000 for surgical abortions < 9 weeks to 8.9 deaths/100000 at > 20 weeks.57 To put this in perspective, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) compiled a 5/12 year database of over 1 million out-patient surgeries performed in ambulatory surgery centers.58 The death rate was 2/100000 for patients that were, on average, significantly older than patients undergoing late abortion. This is only 22% of the mortality rate seen in late abortion. The Canadian counterpart, the Canadian Association for Accreditation of Ambulatory Surgical Centers (CAAASF), conducted a survey that pointed to a death rate of approximately 1/100000 which represents only 11% of the risk of late abortion.59 The risk must be viewed in the context of strict oversight of ambulatory surgical centers in Colorado and the absence of oversight or regulations pertaining to abortion facilities in Colorado.60 Media Trackers reported that “while standard healthcare and out-patient surgical clinics in the state fall under the authority of the Health Facilities division of the Colorado Department of Health and Environment for regular licensing and regulation, Planned Parenthood (and other abortion providers) are not held to the same standard”. Not only does late abortion represent a significant mortality risk to women but the lack of health/safety oversight potentially compounds that risk.

Mortality studies that are based on countries with linked birth, pregnancy, abortion and death registries give an even more stark view of the risk from abortion. In Denmark, the 180-day mortality associated with late abortion (>12 weeks) was 55/100000.61 This is far worse than US surveillance data would suggest and places it in a league with neurosurgery (lumbar discectomy 60/100000), and abdominal surgery (laparoscopic appendectomy, inguinal herniorrhaphy 20/100000, laparoscopic cholecystectomy 200/100000).62-65 While this study is not adjusted for socioeconomic factors, marital status or psychological history, they suggest that mortality risk for women undergoing late abortion might be substantially underestimated in the US.

Some have tried to claim that a legal induced abortion is much safer than childbirth.66 However, others have pointed out that these studies are inherently biased and plagued with differences in ascertainment of deaths, duration of susceptibility to mortality, lack of accounting for gestational age and inappropriate comparators.54 The relative risk of pregnancy associated death between delivery and abortion may be better assessed by looking at countries with linked birth/medical/death databases. A systematic review and meta-analysis suggested that based on 11 studies from three such countries, termination of pregnancy is a marker for reduced life expectancy.67 They found that within a year of their pregnancy outcomes, women experiencing pregnancy loss (from either abortion or natural loss) were twice as likely to die compared to women giving birth. In Denmark this adverse mortality rate persisted for 10 years.61 While there could be confounding variables complicating this analysis, the notion that abortion leads to better health outcomes is unlikely (and certainly speculative without more rigorous research).

The morbidity associated with abortion also increases with gestational age.68 A large retrospective study from the University of California San Francisco suggested that the complication rate for second trimester abortions was 9.8% (including cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception). Major life-threatening complications (complications requiring hospitalization, transfusion, or further surgical intervention) occurred in 1.7% of patients. Any of these complications increased with each additional week of gestation beyond 20 weeks. Unfortunately, there are no published studies specifically addressing the likely extremely high morbidity/mortality associated with third trimester abortions.

Long-Term health effects of abortion are controversial.3 Retrospective studies suggested a correlation of abortion with breast cancer. Better, case control studies suggested no correlation. There appears to be an association of abortion with postpartum hemorrhage in later pregnancies, but the mechanism is undefined. Late abortions may result in an increased risk for premature birth in subsequent pregnancies (aOR= 1.13, 99% CI 0.91-1.4). This trend becomes statistically significant for women who have had multiple abortions. Researchers have found a dose-response relationship between the number of prior abortions and the risk for extreme premature birth. Since black women have, on average, more late abortions and more multiple abortions, one might speculate that the scourge of increased infant mortality (tied largely to premature birth and low birth weight infants) in the black community could be partially caused by abortion.

The adverse effects of abortion on mental health is particularly controversial. Recent reviews cited by abortion proponents rely heavily on the methodologically flawed Turnaway study to conclude that abortion is not associated with new mental health disorders.3 However, a more balanced review of the literature suggests several consensus opinions regarding the nexus between abortion and mental health: “1) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion, 2) the abortion experience directly contributes to mental health problems for at least some women, 3) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion.”69 The reason that this is a particularly urgent issue is that studies suggesting high long-term mortality outcomes from abortion point to markedly increased rates of suicide, accidents, and homicide. 61 ,67, 70

Conclusions:

Late abortion is extreme by any measure and should be prohibited. Very few countries in the world permit abortion after 24 weeks. Most Americans, regardless of their political affiliation, feel that abortion should be illegal in the third trimester. There is irrefutable scientific evidence that a 24-week fetus demonstrates all the fundamental characteristics of more developed humans, including the ability to perceive pain and perform sophisticated sensorimotor behaviors. The reasons women choose late abortions are similar to the reasons that women choose early abortion. Most late abortions are probably performed on normal fetuses. For those tragic situations where a fetus has a life-limiting prognosis because of genetic or congenital fetal abnormality, perinatal hospice offers a compassionate, life-affirming alternative to abortion. Late abortions are violent procedures that commonly involve the crushing and dismemberment of the fetus. Late abortions pose a substantial morbidity and mortality risk to the pregnant woman, which is further exacerbated by the lack of regulatory oversight. Long term sequelae of abortion include the risk for future premature birth and adverse future pregnancy outcomes. There appears to be a substantially increased risk of early mortality in women who have abortion compared to women who deliver babies. This may be related to worse long-term mental health outcomes for women who choose abortion.

References:

1.State Policies on Later Abortions. (2019, January 1). Retrieved from https://www.guttmacher.org/state-policy/explore/state-policies-later-abortions. January 10, 2019

2.Lee, M. Y. H. (2017, October 9). Is the United States one of seven countries that ‘allow elective abortions after 20 weeks of pregnancy?’. The Washington Post.

3.Committee on Reproductive Health Services. The Safety and Quality of Abortion Care in the United States. Washington DC: The National Academy Press, 2018.

4.The Editorial Board of the New York Times. (2018, December 28). A Woman’s Rights. The New York Times. Retrieved from https://www.nytimes.com/interactive/2018/12/28/opinion/abortion-murder-charge.html. January 10, 2019.

5.Trimesters Still Key to Abortion Views. (2018, June 13). Retrieved from https://news.gallup.com/poll/235469/trimesters-key-abortion-views.aspx. January 10, 2019.

6.Moore, KL, Persaud, TVN, and M Torchia. The Developing Human: Clinically Oriented Embryology. 2013. Elsevier Saunders. Print.

7.Moldenhauer JS and Adzick NS. Fetal Surgery for myelomeningocele: After the Management of Myelomeningocele Study (MOMS). Seminars in Fetal & Neonatal Medicine 2017; 22: 360-366.

8.Graves CE, Harrison MR, and Padilla BE. Minimally Invasive Fetal Surgery. Clin Perinatol 2017; 44: 729-751.

9.Ahmad KA, Frey CS, Fierro MA, Kenton AB, and Placencia FX. Two-Year Neurodevelopmental Outcome of an Infant Born at 21 Weeks’ 4 Days’ Gestation. Pediatrics 2017; 140(6): e20170103.

10.Rysavy MA, et. al. Between Hospital Variation in Treatment and Outcomes in Extremely Preterm Infants. NEJM 2015; 372: 1801-1811.

11.Sharp M, French N, McMichael J and Campbell C. Survival and Neurodevelopmental Outcomes in Extremely Preterm Infants 22-24 weeks of gestation born in Western Australia. J Paediatr Child Health 2018; 54(2): 188-193.

12.Sekulic S, et.al. Appearance of fetal pain could be associated with maturation of the mesodiencephalic structures. Journal of Pain Research 2016; 9: 1031-1038.

13.Lee SJ, et.al. Fetal Pain: A Systematic Multidisciplinary Review of the Evidence. JAMA 2005; 294(8): 947-954.

14.Ferschl M, et.al. Anesthesia for In Utero Repair of Myelomeningocele. Anesthesiology 2013; 118(5): 1211-1223.

15.Reissland N, Francis B, Mason, J. Can Healthy Fetuses show Facial Expressions of “Pain” or “Distress”. PLoS ONE 2013; 8(6): e65530. Doi:10/1371/journal.pone.0065530.

16.Bernardes S, et.al. On the feasibility of accessing acute pain-related facial expressions in the human fetus and its potential implications: a case report. Pain Reports 2018; 3: e673

17.McPherson C, Inder T. Perinatal and neonatal use of sedation and analgesia. Seminars in Fetal and Neonatal Medicine 2017; 22: 314-320.

18.Fagard J, et.al. Fetal Origin of Sensorimotor Behavior. Frontiers in Neruorobotics 2018; 12:23.doi:10.3389/fnbot.2018.00023.

19.Hepper PG, Shahidullah BS. Development of Hearing. Archives of Disease in Childhood 1994; 71: F81-F87.

20.Gerhardt KJ, Abrams RM. Fetal exposures to sound and vibroacoustic stimulation. J Perinatol 2000; 20 (8 Pt2): S21-30.

21.Granier-Deferre C, et.al. A Melodic Contour Repeatedly Experienced by Human Near-Term Fetuses Elicits a Profound Cardiac Reaction One Month after Birth. PLoS one 2011; 6(2)L e17304. doi:10.1371/journal.pone.0017304.

22.Biggs MA, Gould H, and Foster DG. Understanding why women seek abortions in the US. BMC Women’s Health 2013; 13: 29.

23.Pappas S. (2011, December 16). Study Reveals Who Gets Late-Term Abortions. Live Science. Retrieved from https://www.livescience.com/17529-trimester-abortions.html , on January 10, 2019.

24.Foster DG and Kimport K. Who Seeks Abortions at or After 20 weeks. Perspectives on Sexual and Reproductive Health 2013; 45(4): 210-218.

25.Llevitan D. (2015, September 29). Clinton Off on Late-Term Abortions. Fact Check.Org. Retrieved from https://www.factcheck.org/2015/09/clinton-off-on-late-term-abortions/. On January 10. 2019.

26.Pavone, F. (2019, February 4). LISTEN: Undercover Call Catches Abortion Clinic Offering to Kill Baby at 32 Weeks. Retrieved from https://www.lifenews.com/2019/02/04/listen-undercover-call-catches-abortion-clinic-offering-to-kill-baby-at-32-weeks/. Retrieved February 4, 2019.

27.Vial, B. (2019, February 8). What It Was Like to Get a Later Abortion. Retrieved from https://www.teenvogue.com/story/what-it-was-like-to-get-a-later-abortion. Retrieved February 8, 2019.

28.Tolentino, J. (2013, September 20). Interview with Dr. Retrieved from https://www.thehairpin.com/2013/09/interview-with-dr/. Retrieved February 10, 2019.

29.Shane, M and Wilson, L. (Producers) & Shane M and Wilson, L (Directors). 2013. After Tiller (Documentary). USA. Roco Distributors.

30.Boulder Abortion Clinic Abortion Services Overview. Retrieved from http://drhern.com/en/abortion-services/abortion-procedures-overview.html. Retrieved February 10, 2019

31.Kirchoff, C. (2019, February 19). Undercover: Late Term Abortion Clinics Exposed. Retrieved from https://www.louderwithcrowder.com/undercover-late-term-abortion-clinics-exposed/. Retrieved February 19, 2019.

32.Perinatal Hospice & Palliative Care. Retrieved from https://www.perinatalhospice.org/. Retrieved January 10, 2019.

33.Barstow D. (2009, July 25). An Abortion Battle, Fought to Death. The New York Times. Retrieved from https://www.nytimes.com/2009/07/26/us/26tiller.html. January 10, 2019.

34.Colorado Department of Public Health and Environment, 2017 Report on Induced Terminations of Pregnancy.

35.Guttmacher Institute. State Facts About Abortion Colorado. Retrieved from https://www.guttmacher.org/sites/default/files/factsheet/sfaa-co.pdf. January 10, 2019

36.Richardson JH. (2009, August 5). The Last Abortion Doctor. Esquire. Retrieved from https://www.esquire.com/news-politics/a6117/abortion-doctor-warren-hern-0909/. January 10, 2019.

37.The Editorial Board of the New York Times. (2018, December 28). Women’s Rights Part 3: The Cost of Complacency About Roe. The New York Times. Retrieved from https://www.nytimes.com/interactive/2018/12/28/opinion/pregnancy-women-pro-life-abortion.html?module=inline. January 10, 2019.

38.Hern WM. Fetal diagnostic indications for second and third trimester outpatient pregnancy termination. Prenatal Diagnosis 2014; 34: 438-444.

39.Goodwin TM. Medicalizing Abortion Decisions. First Things. Retrieved from https://www.firstthings.com/article/1996/03/003-medicalizing-abortion-decisions. Retrieved on January 10, 2019.

40.Hern WM. September 9, 2015. Personal Communication.

41.Cunningham, FG et. al., Williams Obstetrics. McGraw Hill. 2014. Print.

42.Denny, CC. Induction of fetal demise before pregnancy termination: Practices of Family Planning Providers. Contraception 2015; 92(3): 241-245.

43.White, KO et.al., Second-trimester surgical abortion practices in the United States. Contraception 2018; 98(2): 95-99.

44.FDA. Potassium Chloride Injection. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/019904s014lbl.pdf. Retrieved January 10, 2019.

45.Ovender L, Moodley J. Late termination of pregnancy by intracardiac potassium chloride injection: 5 years’ experience at a tertiary referral centre. S Afr Med J. 2012; 103(1): 47-51.

46.Society of Family Planning Clinical Guidelines. Induction of fetal demise before abortion. Contraception 2010; 81: 462-473.

47.Pincus, M. Management of digoxin toxicity. Australian Prescriber 2016; 39: 18-20.

48.Yang, EH, Shah, S and Criley, JM. Digitalis toxicity: A fading but crucial complication to recognize. The American Journal of Medicine 2012; 125(4): 337-343.

49.Moffett, BS, et.al., Serum digoxin concentrations and clinical signs and symptoms of digoxin toxicity in the pediatric population. Cardiol Young 2016; 26(3): 493-498.

50.Nucatola, D. Roth, N, and Gatter, M. A randomized pilot study of the effectiveness and side effects of two doses of digoxin as fetocide when administered intraamniotically or intrafetally prior to second-trimester surgical abortion. Contraception 2010; 81: 67-74.

51.Borgatta, L. et., al., Relationship of intraamniotic digoxin to fetal demise. Contraception 2010; 81: 328-330.

52.Finn, M. (2017, February 7). I had a Late-Term Abortion. President Trump and Pro-lifers have no Right to call me a Murderer. Slate. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/019904s014lbl.pdf. Retrieved February 7, 2019.

53.Douthat, R, Goldberg, M, and Leonhardt D. (2019, February 7) The New York Times - The Argument: The Abortion Debate [Audio Podcast]. Retrieved from https://www.nytimes.com/2019/02/07/opinion/the-argument-abortion-medicare-for-all.html?emc=edit_ty_20190207&nl=opinion-today&nlid=6448792420190207&te=1. Retrieved February 7, 2019.

54.Thorp, JM. Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later. Scientifica 2012; Article ID 980812.

55.Upadhyay, UD et.al., Incidence of Emergency Department Visits and Complications after abortion. Obstetrics & Gynecology 2015; 125(1): 175-183.

56.Bartlett, LA, et.al., Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol 2004; 103(4): 729-737.

57.World Health Organization, Safe Abortion: technical and policy guidance for health systems . 2012.

58.Keyes, GR et.al., Mortality in Outpatient Surgery. Plast Reconstr Surg 2008; 122: 245-250.

59.Ahmad, J. et.al., Assessing patient safety in Canadian ambulatory surgery facilities: A national survey. Plast Surg 2014; 22(1): 34-38.

60.Media Trackers Colorado. Planned Parenthood Clinics Not Regulated by Colorado Health and Medical Standards. March 18, 2013. Retrieved from https://www.redstate.com/diary/pwatson/2013/03/18/colorado-planned-parenthood-clinics-not-regulated-by-standard-state-health-and-medical-guidelines/. Retrieved on February 16, 2019.

61.Reardon, DC and Coleman, PK. Short and long term mortality rates associated with first pregnancy outcome: Population register based study for Denmark 1980-2004. Med Sci Monit 2012; 18(9): PH71-76.

62.Pugely, AJ, et.al., Outpatient Surgery reduces Short-Term Complications in Lumbar Discectomy. Spine 2013; 38(3): 264-271.

63.Frazee, RC et.al., Outpatient Laparoscopic Appendectomy: Is it Time to End the Discussion? J Am Coll Surg 2016; 1-5.

64.Saleh, F et.al., Safety of laparoscopic and open approaches for repair of the unilateral primary inguinal hernia: an analysis of short term outcomes. The American Journal of Surgery 2014; 208: 195-201.

65.Rao, A, et.al., Safety of Outpatient Laparoscopic Cholecystectomy in the Elederly: Analysis of 15,248 Patients Using the NSQUIP Database. J Am Coll Surg 2013; 217: 1038-1043.

66.Raymond, EG and Grimes, DA. The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics and Gynecology 2012; 119(2): 215-219.

67.Reardon, DC and Thorp, JM. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. Sage Open Medicine 2017; 5: 1-17.

68.Ledeerie, L et.al., Obesity as a Risk Factor for Complications after Second Trimester Abortion by Dilation and Evacuation. Obstet Gynecol 2015; 126(3): 585-592.

69.Reardon, DC. The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. AAGE Open Medicine 2018; 6: 1-38.

70.Jalanko, E. et.al., Increased risk of premature death following teenage abortion and childbirth – a longitudinal study. Eur J Public Health 2017; 27(5): 845-849.