As you know from reading this series here on The Pulse, ever since the Supreme Court of the United States (SCOTUS) decided the Dobbs versus Jackson Women’s Health Organization abortion case, we have been comparing the laws related to abortion and similar issues from US state to US state, region by region. SCOTUS decided the Dobbs case in a way that overturned the 1973 Roe v Wade decision, with a 5-4 majority. In the aftermath of this decision, the United States is now a patchwork of very different laws when it comes to reproduction and abortion in particular. In some states, reactions to the Dobbs decision affects, not only abortion care, but other, related issues, such as fertility treatment and contraception. In many cases, pregnancy care itself is not optimal, because laws that criminalize elective abortion could be applied against those who perform or receive medically necessary abortions, or even in cases of procedures to treat ectopic pregnancy or that remove dead products of conception following missed abortions (a type of miscarriage). Tragically, there have been a growing number of cases of antiabortion pharmacists denying women, men, and children medications that they must take for chronic diseases, such as systemic lupus erythematosus or rheumatoid arthritis, due to the fact that certain medications could be used as abortifacients, agents that provoke abortion. But such extreme cases have occurred, only in certain locations. States, such as Tennessee, Georgia, Alabama, Arizona, and Missouri are extremely hostile to the right to choose, while various pro-choice states. Various other states, such as New York, Connecticut, Illinois, Oregon, and Washington are very supportive of the right to choose.
Today, we’re highlighting the US territory island of Puerto Rico, which has a very unusual history on the abortion issue. First, let’s discussion the current situation, meaning as of the end of October when I am writing this. Abortion is legal throughout Puerto Rico. There is no parental notification requirement for abortion in a minor, which Puerto Rico defines as being under the age of 21. This past June, a few days prior to the Dobbs decision, the Puerto Rico Senate actually voted in favor of a bill to ban abortion after 22 weeks gestation, but the Puerto Rico House of Representatives voted against the ban. This keeps abortion legal in Puerto Rico, even beyond 22 weeks. This means that there is no issue surrounding fetal viability (24-26 weeks gestation), which mostly relates to the maturity of the fetal lungs. The House vote was in line with polling showing that 77 percent of Puerto Ricans do not think that the government should interfere with an abortion, that the decision should belong to the woman. Interestingly, this also means that any battle over the right to abortion in Puerto Rico involves a line in the sand around 22 weeks, which is close to the cut-off point for abortion in many US states that are pro-choice.
If you live in Puerto Rico and want to terminate your pregnancy, you can have a procedural abortion at any point. Additionally, you 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.
Puerto Rico has a long history of legalized abortion. The right to terminate a pregnancy became law back in 1937, meaning 36 years ahead of the Roe v Wade decision of 1973. Initially, the underlying reasoning for abortion in the Puerto Rico of the 1930s was not as much about a woman’s right to choose as it was part of a philosophy involving fear of overpopulation that may have had some racial component. This was linked with some sterilization efforts against non-Caucasian peoples that had emerged as part of Eugenics movements of the early 20th century. Regardless of this somewhat murky beginnings of the right to abortion in Puerto Rico, from 1937 onward, the island became a frequent destination of women the mainland US seeking abortions. Along with being legal for all of those years prior the Roe decision, abortion in Puerto Rico also was relatively inexpensive, although, of course the cost of travel from the mainland was very high. This meant that well-to-do woman who desired abortion prior to the late 1960s and early 70s when various US states, such as New York liberalized abortion laws, always had Puerto Rico on their radar screens. Now, the island is simply one more US location where abortion laws are very liberal.