FIGO position statement on the recent prohibition of induction of fetal asystole for legal abortions in Brazil

In many countries around the world, women and girls facing the need for abortion at advanced gestational ages encounter significant barriers to accessing safe services. These women and girls are among the most vulnerable, are often subject to heightened stigma and persecution, and experience more severe complications and higher mortality rates when forced to resort to unsafe abortion practices. 

Restrictive laws that deviate from World Health Organization (WHO) recommendations against imposing time limits, coupled with a shortage of trained providers, further exacerbate injustices towards these individuals. In regions where legislation allows for safe abortion services in later stages of pregnancy, it is the ethical and professional obligation of health care professionals to uphold access and quality, and to challenge any barriers that aggravate existing structural factors. 

In Brazil, induced abortion is legal in three circumstances: when pregnancy is derived from rape, when there is risk to the pregnant woman’s life, and when there is a diagnosis of fetal anencephaly. Under these three circumstances, there is no gestational age limit to access the right to a safe abortion in the text of Brazilian law. However, the Brazilian Federal Council of Medicine recently issued a resolution that prohibits^† the induction of fetal asystole for legally induced abortions, undermining these rights.

Prohibition is unethical and contradicts medical evidence 

FIGO expresses deep concern regarding the recent resolution issued by the Brazilian Federal Council of Medicine that prohibits the induction of fetal asystole for legally induced abortions. This prohibition in Brazil is unethical and contradicts medical evidence. 

For abortion procedures that are performed after 20 weeks’ gestation, scientific evidence supports considering the induction of fetal asystole to prevent signs of life during medical (induced) abortion or fetal expulsion after cervical priming but before a planned dilatation and evacuation (D&E) procedure. The likelihood of transient neonatal survival after expulsion increases with gestational age and the interval between cervical priming and abortion. For medical abortion beyond the viability limit,^‡ induction of fetal asystole should always be an option. 

Prohibition impedes access to quality abortion care for women with advanced pregnancies (beyond viability) who are otherwise entitled to legal abortion in Brazil. The induction of fetal asystole in advanced induced abortions is an essential component of standard quality care and aligns with the intended outcome of abortion, which is never a live birth.^{1, 2} 

Prohibition prevents obstetricians and gynaecologists from adhering to the ethical principle of beneficence. It is well-established that induced safe abortion is safer than childbirth, even at advanced gestational ages.³ Termination of pregnancy without induction of fetal asystole constitutes an induction of a preterm live birth (which is by definition not an abortion). Without induction of fetal asystole, abortions beyond the limit of viability become impossible to provide and women will be forced to either continue their pregnancy and assume the risks of childbirth at term and of forced motherhood, or resort to very unsafe abortions. Thus, the prohibition violates women’s right to access and benefit from modern scientific technologies for safe abortion.⁴ 

Prohibition contravenes the ethical principle of non-maleficence by potentially subjecting women and a newborn to the harms of prematurity if advanced pregnancies are terminated without inducing fetal asystole. Terminating an advanced pregnancy without the induction of fetal asystole could result in transient signs of life or even in survival, with all the complications associated with prematurity (including respiratory distress, patent ductus arteriosus, severe intraventricular haemorrhage, necrotising enterocolitis, late-onset sepsis, bronchopulmonary dysplasia requiring supplemental oxygen and retinopathy).⁵ Fetal asystole induction is therefore necessary to prevent avoidable risks to newborns and ensure non-maleficence, as well as to avoid legal implications for doctors facing care obligations towards neonates with signs of life. 

Prohibition violates the elimination of torture or other cruel, inhuman or degrading treatment established by the United Nations Human Rights Council. Banning fetal asystole induction may force obstetricians and gynaecologists to refuse legally requested abortion care because of their commitment to cause no harm to a newborn. Such refusal would constitute a violation of the pregnant person’s right to be free from torture and other cruel, inhuman or degrading treatment or punishment.⁶ 

Prohibition fosters a false assumption that studies on premature infants are applicable to aborted fetuses, using the rhetoric of viability. Viability is a medical concept relevant only to neonatal care and intensive care provision in the context of spontaneous or medically indicated preterm delivery.^7,8 It is not relevant to induced abortions. Even under the applicable context, preterm delivery is a last-resource measure in obstetrics since any harm to the newborn, as mild as it could be, should be avoided. The studies with premature infants cited in the resolution of the Federal Council of Medicine in Brazil are related to unavoidable preterm deliveries and should not be generalised to aborted fetuses.^{9, 10} This purposeful misinterpretation also trivialises the risks of prematurity. 

Prohibition will adversely affect public health indicators by potentially falsely increasing neonatal and infant mortality and morbidity rates.

Ensuring safe and respectful care

FIGO reiterates that the induction of fetal asystole must be considered and legally permitted as a therapeutic intervention to ensure a safe medically inducted abortion at advanced gestational stages when extrauterine viability is possible. The practice enables care to be delivered in a way that respects the pregnant person’s autonomy and protects them from harm. Prohibiting fetal asystole – with the consequent risk of live births resulting from lawful abortion requests – undermines access to safe abortion care. In Brazil, it deprives health care professionals of the ability to uphold the rights of women and girls that are recognised by Brazilian law. Such prohibition widens social disparities and injustices: it sets a dangerous precedent for the entire region, threatening the significant progress made in this area in recent years. 

References 

1. World Health Organization (WHO). Clinical practice handbook for quality abortion care. Geneva: WHO, 2023. Available at: www.who.int/publications/i/item/9789240075207 
2. World Health Organization (WHO), International Classification of Diseases 11th Revision (2022). The global standard for diagnostic health information. Available at: https://icd.who.int/browse11/lm/en#/http://id.who.int/icd/entity/151711…;
3. Bartlett LA, et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 2004 Apr;103(4):729-37. 
4. CESCR. General Comment Nº 25: Science and economic, social and cultural rights. Article 15(1)(b), (2), (3) and (4) of the International Covenant on Economic, Social and Cultural Rights. United Nations, 2020 (UN Doc. E/C.12/GC/25). 
5. Stoll BJ, et al; Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010 Sep;126(3):443-56. 
6. United Nations. General Council. Human Rights Council. A/HRC/22/53. Report of the Special Rapporteur on torture and other cruel, inhuman, or degrading treatment or punishment, Juan E. Méndez. Paragraphs 49 and 50. 
7. Nuffield Council of Bioethics. Critical care decisions in fetal and neonatal medicine: ethical issues. London: Nuffield Council of Bioethics, 2006. 
8. Romanis EC. Is 'viability' viable? Abortion, conceptual confusion and the law in England and Wales and the United States. J Law Biosci. 2020 Oct 9;7(1): lsaa059. 
9. Brumbaugh JE,et al. Outcomes of Extremely Preterm Infants With Birth Weight Less Than 400 g. JAMA Pediatr. 2019 May 1;173(5):434-445. 
10. Tyson JE, et al.; National Institute of Child Health and Human Development Neonatal Research Network. Intensive care for extreme prematurity--moving beyond gestational age. N Engl J Med. 2008 Apr 17;358(16):1672-81.

^† Although a prohibition of induction of fetal asystole by the Federal Council of Medicine does not constitute a law in Brazil, it is valid throughout the national territory to all Brazilian doctors. As in Brazil legally induced abortions should only be provided by doctors according to the text of the law, the resolution published by the Federal Medical Council ends up restricting medical practice towards induced abortions. 

^‡ The concept of viability is variable and depends on the context and technology available.