What is a 'fetal heartbeat?' What you should know about Iowa's new 6-week abortion bill

A newly passed Iowa bill would ban nearly all abortions after a "fetal heartbeat" is detected around the sixth week of pregnancy — but Iowa doctors say the term inaccurately characterizes that stage of development and the approved bill raises a host of potential complications.

Lawmakers converged on Des Mointo to pass the bill Tuesday in a marathon special session. Gov. Kim Reynolds said she would sign it into law Friday.

It would go into effect immediately.

The passed legislation is nearly identical to a 2018 law that would have prohibited most abortions after cardiac activity is detected in the embryo. That law — which supporters refer to as the "Fetal Heartbeat Law" — was permanently blocked by the courts before it took effect.

“I understand that not everyone will agree with this decision,” Gov. Kim Reynolds said as she signed the law in 2018. “But if death is determined when a heart stops beating, then doesn’t a beating heart indicate life?”

As Republican lawmakers once again passed the restriction, medical professionals say it's misleading to claim an embryo has a heartbeat at six weeks of gestation.

"In medicine, we would never refer to it as a 'fetal heartbeat,'" said Dr. Sarah Traxler, chief medical officer for Planned Parenthood North Central States.

Here's what you need to know about how doctors define and detect cardiac activity, and what it means for Iowa's impending restrictions on abortion.

What is a fetal heartbeat?

The new bill defines "fetal heartbeat" as cardiac activity, or "the steady and repetitive rhythmic contraction of the fetal heart within the gestational sac." Doctors can detect that rhythmic contraction at around six weeks of gestation.

Physicians say calling the cardiac activity at this stage of pregnancy a "fetal heartbeat" is a misnomer.

At six weeks, the pregnancy is still in the embryotic stage. An embryo does not become a fetus until about nine weeks of pregnancy. In addition, an embryo does not have a heart at that stage of pregnancy.

Instead, at about six weeks, the embryo has developed a cluster of cells that generates sporadic electrical impulses, said Dr. Emily Boevers, an OB-GYN practicing in Waverly.

The cells that become the heart begin to develop at about 5 weeks gestation, or five weeks after the first day of the last menstrual period, said Dr. Andrea Greiner, an OB-GYN in Iowa City. Though these cells start contracting early on in the pregnancy, she said, they are not moving blood through the embryo as a fully formed heart would.

These cells will eventually become different parts of the heart — including four heart chambers, valves, arteries and blood vessels of the heart — but those complex structures of the organ are not formed until about 10 weeks gestation, she said.

When can this cardiac activity be detected?

Traxler said the first cardiac activity can be detected as early as 6 weeks gestation, although the exact time varies between individuals.

"In medicine, there are few things that are black and white," she said. "It's sometimes earlier for some folks, it's a little bit later for other folks. It also depends on your type of ultrasound that you use, vaginal ultrasound versus transabdominal ultrasound. It also depends on the modernness of your technology."

The bill specifies a physician should use an abdominal ultrasound to test whether cardiac activity is detectable. Traxler said most modern ultrasound machines can detect cardiac activity at around six weeks.

However, there's some disagreement among providers, as Greiner said early cardiac activity can't reliably be detected by abdominal ultrasounds until later on in pregnancy, at about 10 weeks gestation. Detection of cardiac activity often varies on a variety of factors, such as the pregnant woman's body weight or the position of the uterus.

Cardiac activity can be detected at about six weeks using a transvaginal ultrasound, which is more invasive than an abdominal ultrasound but more accurate in detecting these early electrical impulses, Greiner said.

Cardiac activity can be seen on an ultrasound in the second trimester, at about 17 to 20 weeks, providers say.

Do people know they are pregnant at 6 weeks?

Many people may not realize they are pregnant until they are past six weeks of gestation, Traxler said.

"The vast majority of people present to us after six weeks since their last menstrual period," she said.

Women who use contraception may not realize when those methods fail. Patients with irregular periods may not notice their missed period soon enough. Others may experience "implantation bleeding" in early pregnancy and mistake that for a period.

Most abortions in Iowa take place before 14 weeks gestation, according to a state report. In 2021, nearly 95% of Iowa's 3,761 abortions took place between zero and 13 weeks gestation.

Traxler said most of those abortions occur in the window between six and 12 weeks.

Can cardiac activity be detected in ectopic and other non-viable pregnancies?

Yes, cardiac electrical impulses can be detected in scenarios where the pregnancy is not viable, Greiner said.

That includes ectopic pregnancies, which occur when a fertilized egg impacts outside the uterus, such as the fallopian tube. These pregnancies can pose a serious risk to the pregnant woman if left untreated.

Iowa's proposed ban does include exceptions in cases of a "medical emergency" to "preserve the life of the pregnant woman" if her life is endangered by "physical disorder, physical illness, or physical injury, including a life-endangering physical condition caused by or arising from the pregnancy" or "when continuation of the pregnancy will create a serious risk of substantial and irreversible impairment of a major bodily function of the pregnant woman."

Medical emergencies within the scope of the bill does not include "psychological conditions, emotional conditions, familial conditions, or the woman’s age."

Still, Greiner said she's concerned that this bill will create delays, even in cases of emergencies, because physicians will be uncertain of their ability to intervene.

"I think this ban would potentially make physicians feel intimidated by the law and reluctant or refuse to recommend abortion as an ectopic pregnancy or other non-viable scenarios, even though these are medical emergencies," Greiner said.

Who would determine when an abortion is permitted under this ban?

To determine whether a person would qualify for an exception to the abortion ban, the bill says physicians should use "reasonable medical judgment," which can be made by a physician "who is knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved."

However, Dr. Jill Meadows, the former medical director of Planned Parenthood of the Heartland, said the decision on whether to perform an abortion will likely not be up to individual physicians. Instead, it will be determined by their health care organization's leadership or their hospital ethics board.

"There’s a lot of bureaucratic red tape that we've seen having a severe impact on women's lives in other states," Meadows said.

Boevers said the language within the bill is vague enough that it would create uncertainty on when a physician is allowed to intervene, even when an individual is facing complications in the pregnancy. She worries physicians will have to wait until their patient's condition worsens, or even close to death, until they're allowed to perform an abortion.

“I could save her life, and I could because I went to school for literal decades and trained for hundreds of hours a week," Boevers said. "What is this world that we're living in that we have to have the permission of these non-trained individuals to tell us whether or not we're allowed to?”

Katie Akin is a politics reporter for the Register. Reach her at [email protected]. Follow her on Twitter at @katie_akin.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at [email protected], at (319) 339-7354 or on Twitter at @Michaela_Ramm.

This article originally appeared on Des Moines Register: What Iowa's new 'fetal heartbeat' bill would mean for abortion