WHILE LEROY CARHART, a doctor who specialises in late-term abortions, was finishing his most recent termination, the manager of his clinic in Bethesda, Maryland, outlined the procedure. Abortions in the second half of pregnancy take between two and four days, said Christine Spiegoski, a nurse wearing a T-shirt that read: “Don’t like abortion? Prevent pregnancy by f**king yourself!” First, the doctor injects potassium chloride or digoxin into the fetus’s heart, killing it within minutes. If he is unable to reach the heart and instead pumps the drug into the amniotic sac, death can take up to 24 hours. Dr Carhart euthanises the fetus at the beginning of the procedure because its tissue and skull then soften and contract, easing removal. At 25 weeks a fetus weighs around a pound and a half and is over a foot long; some of those Dr Carhart aborts are older.
Over the next two or three days, medical staff at the clinic, one of only three in America to provide third-trimester abortions, insert small sticks into the woman’s cervix to stretch it open. Then the woman is induced and the fetus delivered. The goal, says Ms Spiegoski, is a delivery “as much like regular labour as possible”. The procedure she describes is quite different from President Donald Trump’s oft-repeated claim that late-term abortions involve babies being “ripped from their mother’s womb”. But it is not difficult to understand why many people, including those broadly in favour of abortion choice, find it problematic. This is also why Mr Trump has seized upon late-term abortion, the most controversial dimension of an issue that has inflamed American politics for almost half a century, as a campaign issue.
Data on abortion late in pregnancy in America are patchy. Not all states are required to report abortion statistics to the Centres for Disease Control (CDC), a federal agency, and the 40 states that do provide the gestational ages of aborted fetuses use ranges that do not reveal how many terminations take place in the third trimester. Still, the data suggest late abortions are extremely rare. In 2015, 1.3% of abortions took place after 21 weeks. But they carry huge political weight, as Mr Trump, who once described himself as “very pro-choice” is keenly aware.
The two sides in America’s abortion war have driven each other to new extremes this year. A flood of early-abortion laws in conservative states, some tantamount to total bans, have prompted other, socially liberal, states to make it easier to have an abortion at the other end of pregnancy. Meanwhile, the Trump administration has set new rules for Title X, a federal family-planning grant programme dating back to the Nixon administration. Organisations receiving Title-X funding are no longer allowed to provide abortions or refer patients to doctors for them. On August 19th Planned Parenthood responded by announcing it would withdraw from the programme—forgoing some $60m in funding—to avoid the new rules.
Mr Trump’s declaration of war on late abortions, a common theme at his rallies, is not only designed to please the evangelicals who helped elect him in 2016. Gallup polling suggests that whereas a majority of Americans think abortion should “generally be legal” in the first trimester, only 13% think it should in the third.
Dr Carhart says that people would change their minds sharpish if they or someone they loved needed a late abortion. He vowed a decade ago to continue the work of George Tiller, an abortion doctor in Kansas shot dead by an anti-abortion zealot in 2009. Dr Carhart says he is motivated by injustice: women, he says, tend to shoulder the burden of an unwanted pregnancy. “Men…can just walk away if they don’t want anything to do with it,” he says. “It should be both of their responsibilities.” If a woman feels she cannot, “she shouldn’t be punished to go through that.”
Try telling that to those on the debate’s opposite side. In the first seven months of 2019 at least 16 states passed or introduced early abortion bans flouting Roe v Wade, the Supreme Court ruling that in 1973 declared abortion a constitutional right. They were emboldened to do so by Mr Trump’s appointment of Justice Brett Kavanaugh, which gave America’s highest court a solidly conservative majority. They hope that one such law will make it to the Supreme Court and help overturn Roe.
Socially liberal states have pushed back. This year, Illinois, Maine, New York, Rhode Island and Vermont have passed laws loosening restrictions on abortion later in pregnancy, codifying protections for abortion rights, or allowing medical workers other than doctors to perform them.
These measures are in part designed to ensure uninterrupted abortion services if anti-abortionists’ efforts to overturn Roeprove successful. But they are also, like the legislation that sparked them, political. “We wanted to send a message and make it explicit,” says Ann Pugh, a Democratic congresswoman in Vermont who co-sponsored the bill there, “that the very private, personal matter of abortion should be decided by a woman and a medical practitioner.” Vermont is one of seven states that have no laws governing when or for what reason a woman may have an abortion.
Why did the two sides become so polarised? The main reason is the way abortion was legalised. In many countries, abortion laws were voted for by elected politicians or in referendums. In America, a seven-to-two majority of justices declared abortion a constitutional right. Anti-abortionists question the interpretation of the constitution that produced that ruling and are furious their voices were not heard. Abortion advocates remain fired up by the knowledge that Roe could yet be overturned.
Had America’s abortion laws been fought over in Congress, they would probably have been more restrictive. Instead, they are among the most liberal in the world—another reason why abortion is fertile ground for Mr Trump. Of 59 countries that allow abortion on demand, America is one of only seven that allow it after 20 weeks of pregnancy. Supreme Court rulings allow it until the fetus is viable, around 24 weeks.
Thereafter, according to another ruling handed down on the same day as Roe, abortions are allowed if the fetus has an anomaly or the mother’s life or health is at risk. Doe v Bolton defines health in capacious terms, to encompass many aspects of well-being, from the economic to the familial. Research suggests a minority of abortions later in pregnancy are performed because the fetus has an anomaly or the woman’s life is endangered, so most come down to the health exception.
For his part, Dr Carhart says that a woman requesting an abortion “has to be a fairly good storyteller. She has to convince me that this really is a problem. The fact that she wants to get into a size eight bathing suit next week—I’m not going to do it for that.” He will always refuse to perform an abortion if the woman is not certain. “I’d rather do an abortion at 30 weeks than have her come in at eight weeks and have the abortion and all of a sudden realise, ‘I wanted to have that baby’,” he says.
America’s comparatively liberal laws do not mean it is easy to get an abortion. Since 1973, lawmakers have chipped away at Roe by introducing hundreds of state-level regulations. Many of them seem trivial—prescribing, say, the precise width of clinic corridors—but their cumulative effect has been devastating. At least seven states have only one abortion clinic left.
The result of that may be more late abortions. Data are limited, but research by Daniel Grossman, a professor of gynaecology and reproductive sciences at the University of California, San Francisco, found that abortion restrictions introduced in Texas in 2013 led to a 27% increase in second-trimester abortions the following year.
America’s abortion war has curtailed access to abortion in other ways, too. Since 1976 the Hyde Amendment has forbidden the use of federal funds for abortion. Some women may have to delay abortions while they raise cash to pay for it. Dr Carhart, meanwhile, says he has performed abortions late in pregnancy because pro-life doctors have chosen not to tell their patients the fetus they are carrying has an anomaly—and then a few weeks before the due date warn them about the condition.
He says that women often ask for tips on how to disguise their abortions from their doctors for fear they refuse to see them again. “I say to them, why the hell do you want to see that doctor anyway?” He advises those women to find a doctor who shares their beliefs. Even the medical profession is polarised. The only thing that could end America’s destructive abortion war is a political consensus. That, unfortunately, is unimaginable.■