Understanding feticide: an analytic review

Too big, too young, too risky: How diagnosis of the foetal body determines trajectories of care for the pregnant woman in pre-viability second trimester pregnancy loss

Women in the English National Health Service facing pre-viability second trimester pregnancy loss through foetal death, premature labour or termination of pregnancy for foetal anomaly find themselves in a particular trajectory of care. This usually involves the requirement to labour and birth the foetal body and may involve undergoing feticide in cases of termination. Drawing on ethnographic research investigating women's experiences of second trimester pregnancy loss, I argue that the determining factor affecting care trajectories for the pregnant body is the biomedically diagnosed status of the foetal body. Foetal size, non-viability and the potential for live birth during terminations all structure the healthcare options for the woman facing pregnancy loss in the second trimester. As such, the diagnostic classification of the foetal body in the context of gestational time determines the medical care afforded to the pregnant body. This results in specific consequences for women, whose experiences of, and choices around, second trimester pregnancy loss are constrained by diagnostic and classificatory decisions around the status of the foetal being before legal viability.

How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis

BACKGROUND

Routine third-trimester ultrasound is frequently offered to pregnant women to identify fetuses with abnormal growth. Infrequently, a congenital anomaly is incidentally detected.

OBJECTIVE

To establish the prevalence and type of fetal anomalies detected during routine third-trimester scans using a systematic review and meta-analysis.

SEARCH STRATEGY

Electronic databases (MEDLINE, Embase and the Cochrane library) from inception until August 2019.

SELECTION CRITERIA

Population-based studies (randomised control trials, prospective and retrospective cohorts) reporting abnormalities detected at the routine third-trimester ultrasound performed in unselected populations with prior screening. Case reports, case series, case-control studies and reviews without original data were excluded.

DATA COLLECTION AND ANALYSIS

Prevalence and type of anomalies detected in the third trimester. We calculated pooled prevalence as the number of anomalies per 1000 scans with 95% confidence intervals. Publication bias was assessed.

MAIN RESULTS

The literature search identified 9594 citations: 13 studies were eligible representing 141 717 women; 643 were diagnosed with an unexpected abnormality. The pooled prevalence of a new abnormality diagnosed was 3.68 per 1000 women scanned (95% CI 2.72-4.78). The largest groups of abnormalities were urogenital (55%), central nervous system abnormalities (18%) and cardiac abnormalities (14%).

CONCLUSION

Combining data from 13 studies and over 140 000 women, we show that during routine third-trimester ultrasound, an incidental fetal anomaly will be found in about 1 in 300 scanned women. This information should be taken into account when taking consent from women for third-trimester ultrasound and when designing and assessing cost of third-trimester ultrasound screening programmes.

TWEETABLE ABSTRACT

One in 300 women attending a third-trimester scan will have a finding of a fetal abnormality.

Mothers' Continuing Bond With the Baby: The Case of Feticide

The nature of the ongoing bond maintained by the bereaved with the deceased has attracted considerable attention, but studies have generally ignored postdeath relationships when loss occurs in utero. The goal of this research was to reach an interpretive understanding of the continuing bond experience among Israeli mothers who underwent feticide, examining the strategies they use in maintaining a postdeath relationship with a child they did not know, whose death they chose and witnessed, within a social context that ignores their loss and forces them to silence their grief. The results highlight two themes: (a) strategies for relinquishing connection with the baby and (b) strategies for maintaining a postdeath relationship. These processes partially correspond with two theoretical views that shed light on interpretation of the results: the dual process of coping with bereavement and relational dialectic theory. Implications of the results to the practice of health providers are outlined.

Abortion and Infant Mortality on the First Day of Life

BACKGROUND

Fetal imaging for congenital anomalies increases pregnancy terminations late in gestation.

OBJECTIVES

We assessed whether late-pregnancy terminations can accidentally result in live births, and how these births impact infant mortality rates over time.

METHODS

We carried out a population-level analysis of 12,141 infant deaths in Quebec, Canada from 1986 to 2012. We calculated the proportion of infants born alive who died following pregnancy termination. The exposure was pregnancy termination with or without congenital anomaly recorded on death certificates. The main outcome was mortality on the first day of life by the hour.

RESULTS

Pregnancy termination was the cause of 19.4 infant deaths per 100,000 in 2000-2012, compared with 1.0 per 100,000 in 1986-1999. Most deaths after termination occurred in the first 3 h of life among infants with anomalies who weighed <500 g. In 2000-2012, infants who died following pregnancy termination led to an excess of 0.2 deaths per 1,000 on the first day of life, i.e. an 8.6% increase in the infant mortality rate (p value = 0.002).

CONCLUSIONS

Pregnancy termination in mid-gestation carries the risk of accidental live birth. These neonates increasingly affect infant mortality rates. Better recording is needed, including data on the prevention and management of accidental live births after pregnancy termination.

Silenced voices: Israeli mothers' experience of feticide

The study is a qualitative analysis of 13 interviews with Israeli women who experienced feticide by injection at a late stage of their pregnancy due to fetus abnormality. Neither the public nor health care professionals are fully aware of the implications and significance of feticide to the mother. The goal of this study which was conducted from May 2008 until October 2009 was to understand and give voice to the women's experience. Three themes were discovered: (a) difficult decision making process and outcomes; (b) the unbearable experience of feticide; and (c) feticide as an unspoken experience. Feticide was revealed to incorporate both social and psychological layers; thus, the findings highlight the interface between a personal experience and a social phenomenon. The women's experience is discussed within the Israeli social context, where feticide is a relatively common yet unspoken procedure.

Human Non-persons, Feticide, and the Erosion of Dignity

Feticide, the practice of terminating the life of an otherwise viable fetus in utero, has become an increasingly common practice in obstetric centres around the globe, a concomitant of antenatal screening technologies. This paper examines this expanding practice in light of the concept of human dignity. Although it is assumed from the outset that even viable human fetuses are not persons and as such do not enjoy full membership in the moral community, it is argued that the fact that these are nevertheless human fetuses affords them prima facie moral status. Thus even those who accept a liberal position with regard to therapeutic abortion, should be concerned about these more recent developments. Indeed, how we treat viable human fetuses has implications for our prospective treatment of other human non-persons and could undermine the common human dignity we all share.

Late termination of pregnancy and foetal reduction for foetal anomaly

Late termination of pregnancy is a relatively rare procedure accounting for approximately 1% of all registered terminations in England and Wales; however, with improving detection rates for foetal anomalies, this number is increasing. Surgical dilation and evacuation (D&E) appears to be a safe and cost-effective procedure as long as the clinical expertise exists to provide this service. Medical termination appears equally safe and is best undertaken with the combined use of mifepristone and misoprostol. Foeticide, when required, should be performed from 22 weeks' gestation using strong KCl administered either by cardiocentesis or by cordocentesis. All women should be offered a post-mortem and any other appropriate investigation to allow accurate counselling regarding future pregnancies. The issue of late selective foetal reduction for foetal abnormality is complicated by the need to balance the risks to the healthy co-twin of expectant management versus selective termination.