President of the National College of French Gynecologists and Obstetricians, Israël Nisand is professor emeritus of obstetric gynecology.
Pregnancy Medical Interruption (IMG) [not to be confused with abortion, Editor's note] has been possible since 1975. Two types of medical indications condition it: the indication for maternal cause and the indication for fetal cause. Maternal-related IMG involves taking into account psycho-social causes “when there is a serious danger to the mother's health” . This legal framework has existed since the Law of July 4, 2001 (Public Health Code, article L2213-1 and following; article R2213-1 and following).
The psycho-social IMG (which is part of the maternal indications for IMG and has therefore been practiced since 2001) is currently little implemented by the obstetric gynecology services. It concerns women in a situation of personal danger, violence, major psychological difficulties or extreme precariousness, making it impossible to continue their pregnancy even when they exceed the legal deadline for abortion of 14 weeks of amenorrhea.
These situations take into account, on the one hand, travel abroad for termination of pregnancy, which is expensive or even inaccessible for some women. These displacements also worsen the feeling of dereliction experienced by these women in absolute distress and who feel abandoned at the very moment when they need help and protection the most.Receiving and listening to women, informing them about all the alternatives and psychological, social and medical aids, and discussing within dedicated staff the need to take care of them does not in any way presume the decision-making conclusion of the medical teams requested. .
Receiving and listening to women, informing them about all the alternatives and psychological, social and medical aids, and discussing within dedicated staff the need to take care of them does not in any way presume the decision-making conclusion of the medical teams requested. . But this allows teams to measure the degree of distress, which does not take place when hospital structures immediately turn away women who have exceeded the legal deadline for abortion.
The French National College of Gynecologists and Obstetricians (CNGOF) recommended in December 2019 that these IMGs be formalized in law and in each center in conjunction with the local CPDPN (Multidisciplinary Center for Prenatal Diagnosis) (in charge of an annual assessment of activity with the Biomedicine Agency).The difficult, even dramatic situations experienced by these women who have to make such a request justify the medical teams' reflection processes with clarity and transparency.
The discussion within the service analyzes the degree of distress of the woman (seriousness - certainty - immediacy) and the possible repercussions of the pregnancy for the health of the mother. The difficult, even dramatic situations experienced by these women who have to make such a request justify the reflection processes of the medical teams in clarity and transparency by making full use of the legal provisions of our country.
There is no precise definition of psycho-social distress which is left to the appreciation of doctors as there is no list of malformations which allow access to an IMG for fetal cause. A "particular gravity and the incurability of the fetal disease" are evaluated by the medical team which must decide collegially on these points. It is the same in the IMG for maternal cause where the medical team is then reinforced by the presence of a psychologist or a psychiatrist.
IMG, whether maternal or fetal indication, unlike abortion, does not imply a time limit for its completion. But, the later it is, the heavier it is, not only for the patient but also for the teams. Their role is therefore to compare the stakes for the woman to continue her pregnancy in relation to the gestational age, the advancement of which complicates and significantly increases the gesture.We can only take care of an IMG if we fully validate the imperative need. There is no question that some decide and that others are required to practice actions decided elsewhere.
This is the reason why the link between the medico-social team who accepts the IMG and those who carry out the termination of the pregnancy is fundamental. We can only take care of an IMG if we fully validate the imperative need. There is no question that some decide and that others are required to practice actions decided elsewhere.
The abortion is a woman's right up to 14 weeks of amenorrhea. It is necessary and sufficient that the woman asks for it to obtain it. Beyond 14 weeks of amenorrhea, it is no longer enough to ask to obtain; the psycho-social reasons must convince the medical team, accustomed to this type of request, and all the more so as the gestational age is advanced.There are situations where the mere fact of proposing to maintain the pregnancy until its term could be experienced as added mistreatment, or even an obscene proposition.
If in certain circumstances, it is possible to offer a woman to carry her pregnancy to term in order to then specify her decision in the face of an unwanted child, it happens that this proposal cannot even be considered because of the dramatic context of the onset of pregnancy: incest, rape, mistreatment of women who are often the subject of warlike conflicts outside our borders and who flee families who reject them and arrive late in France, all these situations are destructive dramas. That goes without saying. Of course, the damage has already been done. But there is also a possible catastrophe for the unborn child after such circumstances. There are situations where the mere fact of proposing to maintain the pregnancy until its term could be experienced as added mistreatment, or even an obscene proposition.
The acceptance of an IMG very late in the pregnancy is a decision of extreme gravity, exceptional, that no medical team can face lightly whatever the cause.Variability in appreciation exists for all human decisions. No center has any exclusivity and nothing prevents a patient from turning to another center in the event of a refusal.
Some will say that the assessment of these medico-social situations will not be the same depending on whether the file has been analyzed here or there. This variability in appreciation exists for all human decisions, including in the field of justice. So that no center has any exclusivity and nothing prevents a patient from turning, in case of refusal, to another center.
The ethical principles which support the need to take care of women in serious psycho-social distress are the principles of justice and autonomy, to which must be added the obligation of informed information for women. It is very useful for the law to re-specify this possibility, which clearly appears as an extension of women's rights in our country.