Explained | Ethical and medical dilemma to allow pregnancy termination at 30 weeks

Is an abortion at 30 weeks a clinical problem or an ethical? Who should be saved, a minor rape victim or a premature infant? Hear from the experts.

The Supreme Court (SC) refused to entertain a plea filed by government and medical authorities to reconsider its old decision to allow a 15-year-old rape victim to terminate pregnancy at 30 weeks.

Expressing its disapproval last week (April 30), the SC asked the government to remove the time cap from abortions in case of minor rape victims.

The ruling came in the backdrop of a conflict of interest between the court and a board of specialists from the All India Institute of Medical Sciences (AIIMS) who were reportedly against the termination of an ‘unborn child’.

As per reports, the Additional Solicitor General Ashwarya Bhati and some specialists from AIIMS had filed a curative petition for the court to rethink its earlier directive, saying there were two children to consider, the minor and the 'unborn baby' in her womb.

However, a bench comprising Chief Justice Surya Kant and Justice Joymalya Bagchi noted that it was not for the doctors or the state to decide what was right for a minor rape survivor and asking her to continue with the pregnancy would mean to ask the victim, who is also a child, to live with a permanent scar for life.

As of now, the SC has dropped contempt of court proceedings after getting informed the medical institute has complied with its ruling and the procedure has resulted in the live birth of a baby boy.

While the legal conflict has been resolved, it has opened a door to an ethically complex and clinically challenging question with no straightforward answers.

The extraordinary case raises many pertinent concerns - is an abortion at 30 weeks a clinical problem or an ethical? Who should be saved, a minor rape victim or a premature infant? What happens to the child born out of this situation? Does abortion at 30 weeks still count for pregnancy termination or a premature birth?

Doctors say it's not exactly an abortion

As per fertility experts, an abortion at 30 weeks of gestational age is much closer to a premature childbirth than termination itself.

The Medical Termination of Pregnancy Amendment Act 2021 (MTP) has extended the lawful limit for abortion up to 20 weeks with opinion of one medical professional involved, for pregnancies between 20 and 24 weeks, the opinion of two experts is needed and this provision has only been permitted for people in special categories like health problems, deformities in fetus, rape or incest. Beyond 24 weeks, the clinical propriety of abortion will be assessed by a state-level medical board.

An average pregnancy can last somewhere between 36 and 40 weeks and this case cuts closer to the delivery date.

As per medical doctors, the case falls closer to a childbirth than a delayed abortion and poses serious clinical challenges.

Speaking to DH, Dr Vaishali Sharma, gynecologist and IVF specialist at AIIMS said: “As pregnancy advances, the uterus becomes much larger and far more vascular, its blood supply increases tremendously. The placenta also becomes more deeply attached. Hence, the risk of heavy bleeding, complications rises significantly. Also, the cervix becomes more difficult to dilate safely, and risks like uterine rupture, retained placenta, sepsis, and emergency surgery become much higher. So, the risk for an abortion at 30 weeks is very much real.”

Around 28 weeks of gestation, the fetus also starts to approach viability and it is no more a clinical dilemma alone, experts have said.

“What seems like an outpatient procedure at 12 weeks starts to look like a preterm birth at 30,” said Dr. Sharma.

Aborting a fetus at 30 weeks follows a disturbing protocol - stopping the fetal heartbeat before inducing labour by injecting intracardiac potassium chloride (KCL) or digoxin injection into its heart. 

The treating whitecoats have to confirm the fetal demise before progressing with the labour or surgery.

“The most uncomfortable part of the procedure is that a fetus delivered at 30 weeks is fully formed and potentially viable. In advanced NICU (Neonatal ICU) centers, survival rates at 30 weeks may exceed 90 percent for these babies. This creates enormous ethical and legal complexity,” she added. 

At this point most medical doctors are at a crossroads – should feticide be performed? In the event of a live baby should resuscitation be performed? What should be the protocol if fetus survival is possible? 

“In cases like these, we are not choosing between a mother and a child, we are choosing between two children and it is emotionally devastating for all the parties involved,” said Dr. Sharma. 

An untimely abortion in a minor is a high risk procedure, requiring a backup medical rescue plan, sometimes leading to clinical emergencies like excessive bleeding, incomplete evacuation of the fetus, sepsis and many other unpredictable outcomes.

Healthcare workers are also at the forefront of the conflict, answerable to the guardians, to their ethical protocol and to the legal authorities at the same time.

Speaking to DH, Dr. Archana Dhawan Bajaj, a gynaecologist and IVF expert at Nurture IVF Clinic said: “Consent doesn’t come easy in these sensitive cases. Most of the time, these situations come under the POCSO (Protection of Children from Sexual Offences Act) Act and one can no longer take a call in isolation. Reporting becomes mandatory and with it comes complex bureaucratic steps. Guardian consent, then legal documentation, then going back to the established ethics, also actively protecting the privacy of the victim. We have to make so many challenging decisions all at once. Because of shame and helplessness, minors tend to present pregnancies in advanced gestational ages and it complicates the procedure even more. For us, people in white coats, it is never an easy decision even if it looks like one.”

To nurture what was born out of terror?

As per multiple studies, a pregnancy coming from a severe traumatic experience can destabilise the victim’s psyche and in some cases, the victim struggles to differentiate between the child and the perpetrator, developing ambivalent feelings towards the fetus. Also, pregnancy can deepen the trauma and push the minor to a higher risk of depression and even suicidal tendencies.

Speaking to DH, Aakanksha Sundar, a practicing psychotherapist in Delhi, said: “No one deserves to enter the world already entangled with trauma, resentment, guilt, or unbearable pain. Also, what burden are we planning to place upon the child? A child should never have to become the embodiment of violence in another person’s psyche.”

“We are asking her to nurture what was born from terror. To love where there may only be grief, rage, numbness, or dissociation. To carry the psychic burden of seeing her violation reflected back at her in tangible form.”

In a conflict of interest with the medical doctors, mental health specialists proposed a major traumatic event like rape can deeply fracture a person’s relationship with their body and control and pregnancy shall continue to take away their agency even more.

“Rape is not only a violation of the body, it is a theft of agency, safety, and selfhood. To force a young woman to carry a pregnancy born from that violence is to make the trauma inescapable in her body. Every second of the pregnancy the child shall be reminded of what was taken away from her. So, should we protect her by re-traumatising her?” said Sundar.

Seconding her, Dr. Pavitra Shankar, a psychiatrist at Aakash Healthcare ( Dwarka) said: “Contrary to the temporality of other types of trauma, a pregnancy is a visible, ongoing, and deeply embodied reminder of the assault.”

Most experts agree that pregnancy could re-traumatise a rape victim, particularly more in the case where the survivor is a child with lesser agency.

The court’s stand

In contradiction to the medical opinion, the Supreme Court firmly believed that medical personnel must alone not decide what is right for the people, the Hindu reported.

It stated that a justice body has to see the whole life of the victim ahead and not just a few solitary incidents.

Earlier, the court had observed that to make the minor victim continue with pregnancy, it could violate her right to live with dignity.

Amidst the conflict of interest between the court and the medical body, it is also important to understand the fate of the live births born out of this complicated pregnancy and if the survival rate is high, do these infants develop deformities or continue to live a healthy life.