Induced abortion is the intentional termination of a pregnancy before the fetus can live independently. An abortion may be elective (based on a woman's personal choice) or therapeutic (to preserve the health or save the life of a pregnant woman).
An abortion may be performed whenever there is some compelling reason to end a pregnancy. An abortion is termed "induced" to differentiate it from a spontaneous abortion in which the products of conception are lost naturally (also called a miscarriage).
An abortion is considered to be elective if a woman chooses to end her pregnancy, and it is not for maternal or fetal health reasons. Some reasons a woman might choose to have an elective abortion are:
- Continuation of the pregnancy may cause emotional or financial hardship.
- The woman is not ready to become a parent.
- The pregnancy was unintended.
- The woman is pressured into having one by her partner, parents, or others.
- The pregnancy was the result of rape or incest.
A therapeutic abortion is performed in order to preserve the health or save the life of a pregnant woman. A health care provider might recommend a therapeutic abortion if the fetus is diagnosed with significant abnormalities or not expected to live, or if it has died in utero . Therapeutic abortion may also be used to reduce the number of fetuses if a woman is pregnant with multiples; this procedure is called multifetal pregnancy reduction (MFPR).
A therapeutic abortion may be indicated if a woman has a pregnancy-related health condition that endangers her life. Some examples of such conditions include:
- severe hypertension (high blood pressure)
- cardiac disease
- severe depression or other psychiatric conditions
- serious kidney or liver disease
- certain types of infection
- malignancy (cancer)
- multifetal pregnancy
Abortion has been a legal procedure in the United States since 1973. Since then, more than 39 million abortions have taken place. It is estimated that approximately 1.3–1.4 million abortions occur in the United States annually. Induced abortions terminate approximately half of the estimated three million unplanned pregnancies each year and approximately one-fifth of all pregnancies.
In 2000 an estimated 21 out of 1,000 women aged 15–44 had an abortion. Out of every 100 pregnancies that year that ended in live birth or abortion, approximately 24 were elective terminations. The highest abortion rates in 2000 occurred in New Jersey, New York, California, Delaware, Florida, and Nevada (greater than 30 per 1,000 women of reproductive age). Kentucky, South Dakota, Wyoming, Idaho, Mississippi, Utah, and West Virginia had the lowest rates (less than seven per 1,000 women).
In 2000 and 2001, the highest percentage of abortions were performed on women between the ages of 20 and 30, with women ages 20–24 having the highest rate (47 per 1,000 women). Adolescents ages 15–19 accounted for 19% of elective abortions, while 25% were performed on women older than 30. Approximately 73% of women having an abortion had previously been pregnant; 48% of those had a previous abortion.
Non-hispanic, white women reported the highest percentage of abortions in 2000 and 2001 (41%). African American women accounted for 32%, Hispanic women for 20%, Asian and Pacific Islander women for 6%, and Native American women for 1%. The highest abortion rates occurred among African American women (49 per 1,000 women), with Hispanic and Asian women also reporting higher-than-average rates (33 and 31 per 1,000 women, respectively). The rate was the lowest among white women (13 per 1,000 women).
Abortions are safest when performed within the first six to 10 weeks after the last menstrual period (LMP). This calculation is used by health care providers to determine the stage of pregnancy. About 90% of women who have abortions do so in the first trimester of pregnancy (before 13 weeks) and experience few complications. Abortions performed between 13 and 24 weeks (during the second trimester) have a higher rate of complications. Abortions after 24 weeks are extremely rare and are usually limited to situations where the life of the mother is in danger.
Although it is safer to have an abortion during the first trimester, some second trimester abortions may be inevitable. The results of genetic testing are often not available until 16 weeks gestation. In addition, women, especially teens, may not have recognized the pregnancy or come to terms with it emotionally soon enough to have a first trimester abortion. Teens make up the largest group having second trimester abortions.
Very early abortions cost between $200 and $400. Later abortions cost more. The cost increases about $100 per week between the thirteenth and sixteenth week. Second trimester abortions are much more costly because they often involve more risk, more services, anesthesia, and sometimes a hospital stay. Private insurance carriers may or may not cover the procedure. Federal law prohibits federal funds (including Medicaid ) from being used to pay for an elective abortion.
Medical abortions are brought about by taking medications that end the pregnancy. The advantages of a first trimester medical abortion are:
- The procedure is non-invasive; no surgical instruments are used.
- Anesthesia is not required.
- Drugs are administered either orally or by injection.
- The outcome resembles a natural miscarriage.
Disadvantages of a medical abortion are:
- The effectiveness decreases after the seventh week.
- The procedure may require multiple visits to the doctor.
- Bleeding after the abortion lasts longer than after a surgical abortion.
- The woman may see the contents of her womb as it is expelled.
As of 2003, two drugs were available in the United States to induce abortion: methotrexate and mifepristone.
METHOTREXATE. Methotrexate (Rheumatrex) targets rapidly dividing fetal cells, thus preventing the fetus from further developing. It is used in conjunction with misoprostol (Cytotec), a prostaglandin that stimulates contractions of the uterus. Methotrexate may be taken up to 49 days after the first day of the last menstrual period.
On the first visit to the doctor, the woman receives an injection of methotrexate. On the second visit, about a week later, she is given misoprostol tablets vaginally to stimulate contractions of the uterus. Within two weeks, the woman will expel the contents of her uterus, ending the pregnancy. A follow-up visit to the doctor is necessary to assure that the abortion is complete.
With this procedure, a woman will feel cramping and may feel nauseated from the misoprostol. This combination of drugs is approximately 92–96% effective in ending pregnancy. Approximately 50% of women will experience the abortion soon after taking the misoprostol; 35–40% will have the abortion up to seven days later.
Methotrexate is not recommended for women with liver or kidney disease, inflammatory bowel disease, clotting disorders, documented immunodeficiency, or certain blood disorders.
MIFEPRISTONE. Mifepristone (RU-486), which goes by the brand name Mifeprex, works by blocking the action of progesterone, a hormone needed for pregnancy to continue. It was approved by the Food and Drug Administration (FDA) in September 2000 as an alternative to surgical abortion. Mifepristone can be taken up to 49 days after the first day of a woman's last period.
On the first visit to the doctor, a woman takes a mifepristone pill. Two days later she returns and, if the miscarriage has not occurred, takes two misoprostol pills, which causes the uterus to contract. Approximately 10% will experience the abortion before receiving the dose of misoprostol.
Within four days, 90% of women have expelled the contents of their uterus and completed the abortion. Within 14 days, 95–97% of women have completed the abortion. A third follow-up visit to the doctor is necessary to confirm through observation or ultrasound that the procedure is complete. In the event that it is not, a surgical abortion is performed. Studies show that 4.5–8% of women need surgery or a blood transfusion after taking mifepristone, and the pregnancy persists in about 1%. Surgical abortion is then recommended because the fetus may be damaged. Side effects include nausea, vaginal bleeding, and heavy cramping. The bleeding is typically heavier than a normal period and may last up to 16 days.
Mifepristone is not recommended for women with ectopic pregnancy or an intrauterine device (IUD), or those who have been taking long-term steroidal therapy, have bleeding abnormalities, or on blood-thinners such as Coumadin.
MANUAL VACUUM ASPIRATION. Up to 10 weeks gestation, a pregnancy can be ended by a procedure called manual vacuum aspiration (MVA). This procedure is also called menstrual extraction, mini-suction, or early abortion. The contents of the uterus are suctioned out through a thin plastic tube that is inserted through the cervix; suction is applied by a syringe. The procedure generally lasts about 15 minutes.
A 1998 study of women undergoing MVA indicated that the procedure was 99.5% effective in terminating pregnancy and was associated with a very low risk of complications (less than 1%). Menstrual extractions are safe, but because the amount of fetal material is so small at this stage of development, it is easy to miss. This results in an incomplete abortion that means the pregnancy continues.
DILATATION AND SUCTION CURETTAGE. Dilation and suction curettage may also be called D & C, suction dilation, vacuum curettage, or suction curettage. The procedure involves gentle stretching of the cervix with a series of dilators or specific medications. The contents of the uterus are then removed with a tube attached to a suction machine, and walls of the uterus are cleaned using a narrow loop called a curette.
Advantages of an abortion of this type are:
- It is usually done as a one-day outpatient procedure.
- The procedure takes only 10–15 minutes.
- Bleeding after the abortion lasts five days or less.
- The woman does not see the products of her womb being removed.
- The procedure is invasive; surgical instruments are used.
- Infection may occur.
The procedure is 97–99% effective. The amount of discomfort a woman feels varies considerably. Local anesthesia is often given to numb the cervix, but it does not mask uterine cramping. After a few hours of rest, the woman may return home.
DILATATION AND EVACUATION. Some second trimester abortions are performed as a dilatation and evacuation (D & E). The procedures are similar to those used in a D & C, but a larger suction tube must be used because more material must be removed. This increases the amount of cervical dilation necessary and increases the risk and discomfort of the procedure. A combination of suction and manual extraction using medical instruments is used to remove the contents of the uterus.
OTHER SURGICAL OPTIONS. Other surgical procedures are available for performing second trimester abortions, although are rarely used. These include:
- Dilatation and extraction (D & X). The cervix is prepared by means similar to those used in a dilatation and evacuation. The fetus, however, is removed mostly intact although the head must be collapsed to fit through the cervix. This procedure is sometimes called a partial-birth abortion. The D & X accounted for only 0.17% of all abortions in 2000.
- Induction. In this procedure, an abortion occurs by means of inducing labor. Prior to induction, the patient may have rods inserted into her cervix to help dilate it or receive medications to soften the cervix and speed up labor. On the day of the abortion, drugs (usually prostaglandin or a salt solution) are injected into the uterus to induce contractions. The fetus is delivered within eight to 72 hours. Side effects of this procedure include nausea, vomiting, and diarrhea from the prostaglandin, and pain from uterine contractions. Anesthesia of the sort used in childbirth can be given to reduce pain. Many women are able to go home a few hours after the procedure.
- Hysterotomy. A surgical incision is made into the uterus and the contents of the uterus removed through the incision. This procedure is generally used if induction methods fail to deliver the fetus.
The doctor must know accurately the stage of a woman's pregnancy before an abortion is performed. The doctor will ask the woman questions about her menstrual cycle and also do a physical examination to confirm the stage of pregnancy. This may be done at an office visit before the abortion or on the day of the abortion.
Pre-abortion counseling is important in helping a woman resolve any questions she may have about having the procedure. Some states require a waiting period (most often of 24 hours) following counseling before the abortion may be obtained. Most states require parental consent or notification if the patient is under the age of 18.
Regardless of the method used to perform the abortion, a woman will be observed for a period of time to make sure her blood pressure is stable and that bleeding is controlled. The doctor may prescribe antibiotics to reduce the chance of infection. Women who are Rh negative (lacking genetically determined antigens in their red blood cells that produce immune responses) should be given an injection of human Rh immune globulin (RhoGAM) after the procedure unless the father of the fetus is also Rh negative. This prevents blood incompatibility complications in future pregnancies.
Bleeding will continue for about five days in a surgical abortion and longer in a medical abortion. To decrease the risk of infection, a woman should avoid intercourse, tampons, and douches for two weeks after the abortion.
A follow-up visit is a necessary part of the woman's aftercare. Contraception will be offered to women who wish to avoid future pregnancies, because menstrual periods normally resume within a few weeks.
Complications from abortions can include:
- uncontrolled bleeding
- blood clots accumulating in the uterus
- a tear in the cervix or uterus
- missed abortion (the pregnancy is not terminated)
- incomplete abortion where some material from the pregnancy remains in the uterus
Women who experience any of the following symptoms of post-abortion complications should call the clinic or doctor who performed the abortion immediately:
- severe pain
- fever over 100.4°F (38.2°C)
- heavy bleeding that soaks through more than one sanitary pad per hour
- foul-smelling discharge from the vagina
- continuing symptoms of pregnancy
Usually the pregnancy is ended without complication and without altering future fertility.
Morbidity and mortality rates
Serious complications resulting from abortions performed before 13 weeks are rare. Of the 90% of women who have abortions in this time period, 2.5% have minor complications that can be handled without hospitalization. Less than 0.5% have complications that require a hospital stay. The rate of complications increases as the pregnancy progresses.
Only one maternal death occurs per 530,000 abortions performed at eight weeks gestation or less; this increases to one death per 17,000 abortions performed from 16 to 20 weeks, and one death per 6,000 abortions performed over 20 weeks.
Adoption is an option for pregnant women who do not want to raise a child but are unwilling or unable to have an abortion. Adoption agencies, crisis pregnancy centers, family service agencies, family planning clinics, or state social service agencies are available for women to contact for more information about the adoption process.
Centers for Disease Control and Prevention. "Abortion Surveillance—United States, 1999." Morbidity and Mortality Weekly Report 51 (2002): SS09.
Finer, L. B. and S. K. Henshaw. "Abortion Incidence and Services in the United States in 2000." Perspectives on Sexual and Reproductive Health 35 (2003): 6–15.
Jones, R. K., J. E. Darroch, and S. K. Henshaw. "Patterns in the Socioeconomic Characteristics of Women Obtaining Abortions in 2000–2001." Perspectives on Sexual and Reproductive Health 34 (2002): 226–35.
Alan Guttmacher Institute. 1120 Connecticut Ave., NW, Suite 460, Washington, DC 20036. (202) 296-4012. http://www.agi-usa.org .
Centers for Disease Control and Prevention, Division of Reproductive Health. 4770 Buford Highway, NE, Mail Stop K-20, Atlanta, GA 30341-3717. (770) 488-5200. http://www.prochoice.org .
National Abortion Federation. 1755 Massachusetts Ave., NW, Suite 600, Washington, DC 20036. (202) 667-5881. http://www.prochoice.org .
Planned Parenthood Federation of America. 810 Seventh Ave., New York, NY 10019. (212) 541-7800. http://www.plannedparenthood.org .
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Debra Gordon Stephanie Dionne Sherk
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
An induced abortion must be done under the supervision of a physician. Under normal circumstances, the abortion is performed by a licensed obstetrician or gynecologist. In some states, however, advanced clinicians such as nurse practitioners, certified nurse midwives, or physician assistants can perform an abortion under the direct supervision of a physician.
Most women are able to have abortions at clinics or outpatient facilities if the procedure is performed early in pregnancy and the woman is in relatively good health. Women with heart disease, previous endocarditis, asthma, lupus erythematosus, uterine fibroid tumors, blood clotting disorders, poorly controlled epilepsy, or some psychological disorders usually need to be hospitalized in order to receive special monitoring and medications during the procedure. In 2000 over 93% of abortions were performed in a clinic setting; clinics accounted for nearly half (46%) of all abortion providers. Hospitals were the site of 5% of abortions (accounting for 33% of abortion providers), while only 3% of abortions were performed at physician offices (21% of abortion providers).
QUESTIONS TO ASK THE DOCTOR
- What abortion options are available to me based on my stage of pregnancy?
- What are the short- and long-term complications of the procedure?
- What type of pain relief/anesthesia is available to me?
- Who can be in the procedure room with me?
- What will the abortion cost? What do the fees include?
- Is pre-abortion counseling offered?
- How is follow-up or emergency care provided?
- Does the doctor who will perform the abortion have admitting privileges at a hospital in case of a problem?