The role of paediatrics in the abortion debate.

Abstract

Acta PaediatricaEarly View PERSPECTIVEOpen Access The role of paediatrics in the abortion debate Shannon Y. Adams, Corresponding Author Shannon Y. Adams sadamshartung@luriechildrens.org orcid.org/0000-0002-3691-0984 Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA Correspondence Shannon Y. Adams, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Chicago, IL 60611, USA. Email: sadamshartung@luriechildrens.orgSearch for more papers by this authorNatalia Henner, Natalia Henner Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USASearch for more papers by this authorKatie Watson, Katie Watson Northwestern University Feinberg School of Medicine, Chicago, Illinois, USASearch for more papers by this author Shannon Y. Adams, Corresponding Author Shannon Y. Adams sadamshartung@luriechildrens.org orcid.org/0000-0002-3691-0984 Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA Correspondence Shannon Y. Adams, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Avenue, Chicago, IL 60611, USA. Email: sadamshartung@luriechildrens.orgSearch for more papers by this authorNatalia Henner, Natalia Henner Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USASearch for more papers by this authorKatie Watson, Katie Watson Northwestern University Feinberg School of Medicine, Chicago, Illinois, USASearch for more papers by this author First published: 17 November 2022 https://doi.org/10.1111/apa.16600AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abbreviations AAP American Academy of Pediatrics NICU neonatal intensive care unit OB/GYN obsterics and gyneology 1 INTRODUCTION Medical literature on abortion lives primarily in obstetrics and gynaecology journals. This is likely because obstetrician–gynaecologists perform the vast majority of abortions in the United States. However, one by-product of the designation of abortion as an OB/GYN ‘issue’ is the dearth of data-driven dialogue amongst members of other specialties, specifically paediatrics. A review of paediatric literature shows little-to-no mention of abortion outside of adolescent medicine, where research primarily focuses on abortion access for young adults and the ethical challenges of confidentiality and assent. The American Academy of Pediatrics' statement in response to the Supreme Court's recent decision to overturn Roe v. Wade was consistent with this trend, ‘reaffirming the [AAP's] longstanding policy supporting adolescents' right to access comprehensive, evidence-based reproductive healthcare services, including abortion’.1 However, as the medical-legal landscape of reproductive health rights in America enters a new era, this discourse should go further. Although the paediatric voice has been largely absent from ongoing discussions on abortion, paediatrics belongs at the table as the medical field continues to advocate for the preservation of abortion rights and access. The role of our specialty extends beyond the adolescent population alone, because paediatricians are both conservators of well-being for children from birth to adulthood, and experts in foetal viability. 2 SOCIAL VIABILITY AND THE PAEDIATRIC MISSION A paediatrician's mission is to protect the physical, mental and social well-being of their patients, and it is widely understood that a child's well-being is intimately linked to that of their parents. Laws limiting access to safe and legal abortions for pregnant individuals therefore inherently affect their existing children (59% of patients undergoing abortion are already mothers) and any children they may bear in the future.2 In other words, when the health and welfare of a parent are jeopardised, their children are exposed to the sequalae of that. It is no surprise then that research shows unwanted pregnancies are more frequently associated with worse health outcomes for infants and children.3 Undesired pregnancies carried to delivery are associated with increased rates of maternal psychologic distress,3 decreased breastfeeding rates and poor maternal bonding.4 One study even found a decrease in child development scores for children of mothers who were denied the abortion they sought.5 The reason for these trends is likely multifactorial but may be best explained by the concept of ‘social viability’, defined here as the nonbiological factors that determine a child's potential for emotional, mental and physical health. A socially viable pregnancy is one in which the pregnant person desires the birth of a child (whether they have chosen to raise them, or whether they have actively chosen to carry a child for another identified parent through a surrogacy or adoption plan) irrespective of economic or other factors that may pose future challenges. These children are born into a situation in which someone is committed to safeguarding their growth and is largely able to act on that. As paediatricians, we must recognise that as one practitioner wrote, ‘parental health is infant health, and maternal health is foetal health’“.6 Access to safe abortion for pregnant people therefore not only protects them, it also safeguards their infants and children. Some argue that a pediatric or “pro-child” approach must include the unborn, and therefore oppose abortion because embryos have the potential to become children, or can be seen as the moral equivalent. While we recognise the prevalence of this claim and acknowledge the complexity of the debate around the personhood of embryos and foetuses, we contend that true social viability cannot be manufactured—neither by the medical establishment nor by the law. As paediatricians, our professional mission is centred around the care of the infants and children who fill our clinics and hospitals; the children whose lives need not be imagined. If our job is to protect their well-being, then acknowledging the role of abortion in family planning, parental health and ultimately the preservation of social viability for all children is our job too. 3 FOETAL VIABILITY IN CLINICAL PRACTICE The term ‘foetal viability’ entered public vernacular as a legal determination. In Roe v. Wade (1973), the Supreme Court held that states could not ban abortion before a foetus reaches viability, a decision it affirmed in Planned Parenthood v. Casey (1992). The Roe Court defined viability as the point at which a foetus ‘is potentially able to live outside the mother's womb’, and the Casey Court described it as ‘a realistic possibility of maintaining and nourishing life outside the womb’. The Roe definition of viability went beyond mere survival, explaining that ‘a viable fetus is one capable of meaningful life’. However, the Supreme Court left the interpretation of those definitions to the judgement of medical professionals, acknowledging that medical technology was likely to improve over time. The medical professionals who work with pregnant people, foetuses and neonates, and are therefore responsible for the application of foetal viability in clinical practice, are obstetricians (specifically maternal-foetal medicine specialists) and paediatricians (specifically neonatologists). The primary goal of neonatology is to care for critically ill and premature newborns. Since its establishment by the American Board of Paediatrics in 1975, the field has evolved dramatically, decreasing morbidity and mortality for medically fragile infants by large margins with each decade. In doing so, neonatal clinicians and researchers have continued to change our collective understanding of what maladies and gestational ages allow or preclude survival. But this trajectory has ramifications. In pushing the field forward, there have been unintended effects that have reverberated across different areas of medicine. One such by-product is that the term ‘foetal viability’ has inevitably remained fluid—both in terms of clinical practice and with regard to the law. The Court's 2022 decision in Dobbs v Jackson Women's Health Organisation allows state legislatures to decide if and when abortion will be legal, and what interpretative latitude medical professionals will have. Some states have banned abortion at early gestational ages or altogether, some have imported language like Roe's viability standard into their state law, some have no gestational limit on abortion access, and some are still in the thick of deliberation and litigation. In states where biological viability (gestational, genetic, or multifactorial) remains central, advancements in neonatology continue to redefine this core component of abortion law, with earlier gestational survival potentiating reduced maternal choice. Despite its legal origins and more recent politicisation, the expertise of both maternal foetal medicine and neonatology remains critical to the implementation of ‘foetal viability’ in clinical practice. The nuances of a true viability determination involve decisions grounded in evidence-based medicine: the accuracy of maternal dating, extent of prenatal care and screening, timely provision of antenatal steroids, presence of foetal anomalies, maternal age, maternal pre-existing conditions, institutional resources and guidelines, singleton versus multiple gestation, birthweight and more. As many states prepare to address these topics, if we as paediatricians and researchers are both highly skilled in the practical application of ‘foetal viability’ and integrally involved in its evolution as it pertains to the clinical care of neonates, then we have an ethical and professional obligation to act. In other words, if our work informs the law, it is our duty to be active participants in the creation and interpretation of that law, rather than allowing relevant stakeholders to interpret our data without our voice. 4 CONCLUSION Abortion provision is heavily influenced by every sector of society: politics, religion, economics and media. However, medicine and the expertise of healthcare providers remains a critical voice. In a statement addressing the decision in Dobbs v Jackson, the American College of Obstetricians and Gynaecologists said, ‘[Our] resolve is unwavering: we will continue to support our members, our community partners, and all people in the ongoing struggle against laws and regulations that violate and interfere with the patient–physician relationship and block access to essential, evidence-based health care’. Obstetricians should not shoulder the full weight of that burden alone. Although on the surface it may seem that the care of adolescents is where paediatrics enters this discussion, we call on our specialty to instead recognise and act on its much larger role. There are many ways in which we as paediatricians can advocate for change. One example of a potential legislative adaptation where paediatric expertise could become crucial is in Ohio, where a bill has been introduced that would require invasive intervention for all periviable births despite parental wishes or medical judgement.7 Any state policy considerations responding to advancements in foetal surgery and discussions of resuscitation decisions for periviable infants delivered intraoperatively will also require the active participation of paediatricians.8 Additional advocacy avenues can include statements from paediatric professional societies, allyship with obstetric colleagues, academic scholarship, use of social media platforms or simply letting our families who are faced with these challenges know that we are here for them too. The acknowledgement of equitable abortion access as a vital component of comprehensive health care is the responsibility of everyone in paediatrics—from our NICUs and newborn nurseries to our immediate cares and emergency departments. It is our collective duty as paediatricians, regardless of subspeciality, to listen, engage and speak up on behalf of our patients and their families in support of safe and legal access to abortion. ACKNOWLEDGEMENTS Dr. Shannon Adams conceptualised and developed this project and was responsible for drafting, reviewing and revising the manuscript. Dr. Natalia Henner helped to conceptualise this project and assisted in reviewing and revising the manuscript. Katie Watson assisted in developing, reviewing and revising the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. FUNDING INFORMATION No funding was secured for this project. CONFLICT OF INTEREST All authors have no conflicts of interest to disclose. REFERENCES 1 AAP statement on supreme court decision in Dobbs v. Jackson Women's health Organization 6/24/2022, 2022. 2Watson K, Samuel K. Maternal indications: current or future mothering as a reason for abortion among patients writing in notebooks at one American abortion clinic. SSM Qual Res Heal. 2022; 2022: 100124. 3Aztlan-James EA, McLemore M, Taylor D. Multiple unintended pregnancies in U.S. women: a systematic review. Womens Health Issues. 2017; 27(4): 407- 413. doi:10.1016/j.whi.2017.02.002 4Foster DG, Biggs MA, Raifman S, Gipson J, Kimport K, Rocca CH. Comparison of health, development, maternal bonding, and poverty among children born after denial of abortion vs after pregnancies subsequent to an abortion. JAMA Pediatr. 2018; 172(11): 1053- 1060. doi:10.1001/jamapediatrics.2018.1785 5Foster DG, Raifman SE, Gipson JD, Rocca CH, Biggs MA. Effects of carrying an unwanted pregnancy to term on women's existing children. J Pediatr. 2019; 205: 183- 189 e1. doi:10.1016/j.jpeds.2018.09.026 6Diamond R. A pediatrician's point of view: antiabortion is anti-child. Boston Globe. Accessed September 4, 2022. https://www.bostonglobe.com/2022/05/05/opinion/pediatricians-point-view-antiabortion-is-anti-child/ 7 151, Ohio State Senate, General Assembly 134 sess. 2022. https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA134-SB-151 8Kukora SK, Fry JT. Resuscitation decisions in foetal myelomeningocele repair should center on parents' values: a counter analysis. J Perinatol. 2022; 42(7): 971- 975. doi:10.1038/s41372-022-01385-7 Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation