Feticide and late termination of pregnancy: an essential component of reproductive health care

Decisions about late abortion and care for women and their families are supported by sensitive and professional care

Most pregnant women in Australia undergo some form of antenatal screening for fetal anomalies. This includes ultrasound scanning for fetal structural anomalies and combined first trimester screening, which is largely publicly funded, and non‐invasive prenatal screening for certain chromosomal or genetic conditions, currently available only at private expense.1

Most severe fetal anomalies are detected by 20 weeks’ gestation, and most parents choose to terminate pregnancies in which they are identified, an option available on request in all Australian jurisdictions.2 However, a small number of very severe anomalies and an even smaller number of maternal conditions are not always diagnosable by 20 weeks, and sometimes not until the third trimester, and can therefore be reasons for requesting a termination in the latter part of the second or during the third trimester.3,4

Termination of pregnancy during late gestation is distressing for the parents and can also be challenging for medical and midwifery staff, particularly if the infant shows signs of life after birth. For this reason, it is now common practice to offer parents seeking terminations from 22 weeks’ gestation (and sometimes earlier) feticide by intra‐cardiac injection of potassium chloride, with ultrasound scanning control, to ensure stillbirth.5

These procedures and the associated decisions are not well understood by the general public and not widely discussed even in the medical literature. The article by Rosser and colleagues in this issue of the Journal6 provides a comprehensive account of eleven years’ experience of feticide and late termination at the Royal Brisbane and Women’s Hospital (RBWH). It should do much to dispel myths sometimes peddled by opponents of abortion, while also making clear the enormity of the decision making and the processes required for feticide and late termination for both the parents and the staff providing care.

Rosser and colleagues describe a total of 305 feticide procedures and late terminations. The broad array of health professionals and support staff involved testifies to the complexity of many of these late diagnoses, and to the commitment of medical and other staff to reaching an appropriate decision in each case. Since the Queensland Termination of Pregnancy Act came into force in 2018, the final decision about feticide is made by two doctors, usually maternal–fetal medicine specialists. Maternal–fetal medicine specialists must have advanced technological and clinical skills, and be experts in communication, compassionate, and able to cope with the emotional stress inherent to the situation. The details provided by Rosser and her colleagues indicate that it is occasionally necessary to observe a pregnancy well into the third trimester to be certain of the diagnosis and severity of some conditions, particularly brain abnormalities; their figures can only hint at the drawn‐out tragedy that unfolds for all involved before the final decision is made. The few publications on stress levels among medical and nursing staff engaged in this work indicate that it can be significant.7,8

Rosser and colleagues also hint in a few sentences at another detail of the underlying reality of the situation: the RBWH accepts women requesting feticide or late termination from well outside their catchment area, particularly from southern metropolitan Brisbane, when other practitioners are “unable or unwilling” to provide such services. Brisbane, like many Australian capitals, has two large public maternity hospitals, one administered by the state, the other by a religious organisation. The latter, although taxpayer‐funded and possessing state‐of‐the‐art technology for fetal diagnosis, does not provide or refer women for abortions. Women attending this hospital for antenatal care who receive grim news about the health of their fetus must therefore seek a general practitioner or other doctor to refer them elsewhere, causing delays in appropriate care, increasing their stress, and perpetuating the stigma attached to abortion. In Brisbane, the RBWH accordingly provides feticide services for a disproportionately large number of Queensland women.

The recent overturning of the Roe v Wade ruling by the United States Supreme Court has led to increased attention to abortion services in Australia.9 Over the past quarter century, abortion laws have been reformed and/or abortion decriminalised in all Australian jurisdictions. A majority of Australians support the access of women to safe, legal abortion, and any attempts to re‐criminalise abortion in Australia are highly unlikely to succeed.10 However, individual services could face financial cutbacks or even suspension; we need to be vigilant.

The article by Rosser and colleagues clearly shows that feticide and late termination in Queensland are performed for valid indications, and that a great deal of sensitive and professional care is invested in the decision making processes and the support of women and their families. Services such as that at the RBWH, are a vital part of reproductive health care for women.