Ever since the Dobbs versus Jackson Women’s Health Organization abortion case was decided by the Supreme Court of the United States (SCOTUS), we have been considering issues of abortion and reproductive care state-by-state. That’s because, following the Dobbs decision this past June, the United States became a patchwork of very different laws when it comes to reproduction and abortion. In some cases, US states’ reactions to the Dobbs decision affect not only abortion care, but other, related issues, such as fertility treatment and contraception. The Dobbs decision overturned the 1973 Roe v Wade decision by a majority of 5-4 justices. Laws are extremely hostile to abortion, and with it reproductive health overall, in many states, such states include Mississippi, Tennessee, Georgia, Alabama, Arizona, and Missouri. At the other extreme are pro-choice state, which include New York, Connecticut, Illinois, Oregon, New Mexico, Washington, North Carolina. These certain others are protecting the right to choose up to the point of fetal viability (24-26 weeks gestation) or close to that point, or beyond it. North Carolina, for instance, allows abortion up to 20 weeks and six days, and some states, such as Oregon and New Jersey, have no time limit. There also are in between states, such as Florida, where you can have an abortion up through the 15th week, but even that right stands on shaky ground that depends a lot on outcomes of the November election (which may have taken place by the time that this post publishes). Interestingly, there are some states in which abortion rights are being upheld, despite strong majorities of anti-choice Republican politicians in the state legislatures and governors, because of either the state constitution or the court system. Such states include Kansas, Alaska, Montana, and Ohio. In Kansas, despite its strong Republican leanings and active anti-abortion politicians and organizations, the people out and voted strongly on a ballet measure in favor of keeping a guarantee of the right to choose in the Kansas state Constitution.
Today, we’re visiting Maryland (the Free State) and Delaware (the First State), both of which allow elective termination of pregnancy up to the point of viability, which generally means around 24 weeks gestation or in some cases up to 26 weeks. This is not counting extreme situation, such as when the mother’s life or health is in danger. Generally, women who choose late term abortions do so because prenatal testing revealed some very severe problem with the fetus, indicating that the child will be very sick and will suffer and have a very short life.
If you live in Maryland or Delaware and want to terminate your pregnancy, you can have a procedural abortion at any point up to viability, you also can have a medication abortion up to 77 days (11 weeks) gestation. One type of procedure that can be used for an abortion is called a D&C, which stands for dilatation and curettage. Curettage is a kind of scraping of the inner lining of the uterus. Extracting a pregnancy, either viable or not, is only one of several reasons for performing a D&C. D&Cs can be performed for diagnostic reasons, such as when there’s a suspicion of abnormal cell growth in the endometrium. Therapeutic D&Cs can be performed for removing products of conception, but also for removing overgrowth of the uterine lining.
D&C by itself is adequate only early in pregnancy, so after a certain point the next option is dilatation and suction. This means that, after the cervix is dilated, the doctor suctions out the products of conception. Sometimes this can be done with a syringe, but often it requires power suction. A tube called a cannula is inserted through the opened cervix. Cannulae come in a range of sizes that are chosen based on how far along the pregnancy is, or was before it became inviable. In some cases, following suction, the doctor may then perform some curettage to extract any remaining products of conception.
At some point during pregnancy, generally around the midpoint, suction is not enough to extract either a viable or inviable fetus. In such cases, the OB/GYN must use instruments to grab onto the fetus, or parts of the fetus. Such a procedure is known as a D&E, which stands for dilatation and extraction. The extraction includes not only the fetus, but also the placenta, as well as the membranes. All the products of conception must be removed and accounted for, because products that remain inside the uterus can become infected. In discussing these techniques, notice how we have switched back and forth between mentioning elective and non-elective procedures. That’s because performing any of these procedures requires the same set of skills regardless of whether it’s a medical necessity, such as removal of retained products after a missed abortion, or it’s an unwanted pregnancy.
One limitation to keep in mind in Maryland and Delaware concerns minors. In Maryland if you are under 18 years old, and in Delaware if you are under 16 years old, parental notification is required. This means that at least one of the pregnant young woman’s parent’s must be notified of the abortion, but neither parent is required to give consent. In cases when a minor cannot, or wishes not, to notify a parent, Delaware offers a judicial bypass procedure, in which a judge can grant permission for the abortion, with parental notification. Judicial bypass is not available in Maryland, but there are circumstances in which physicians in Maryland providing the abortion can waive the parental notification requirement.
