Abortion

An abortion is the termination of a pregnancy associated with the death of an embryo or a fetus. This can occur spontaneously, in the form of a miscarriage, or be intentionally induced through chemical, surgical, or other means. The pregnancy of any female mammal can be aborted; however, this article focuses exclusively on the phenomenon in women.

There have been various methods of inducing an abortion throughout the centuries. In the 20th century, the ethics and morality of abortions became the subject of intense political debate in many areas of the world.

Definitions

In medicine, the following terms are used to define an abortion:

• Spontaneous abortion: An abortion due to accidental trauma or natural causes. These are also termed miscarriages.
• Induced abortion: An abortion deliberately caused.

Induced abortions are further subcategorized into therapeutic abortions and elective abortions:

• Therapeutic abortion: An abortion performed because the pregnancy poses physical or mental health risk to the pregnant woman.
• Elective abortion: An abortion performed for any other reason.

A pregnancy that ends early, but where the fetus survives to become a live infant, is termed a premature birth. A pregnancy that ends with an infant dead upon birth, due to causes including spontaneous abortion or complications during delivery, is termed a stillbirth. Using contraceptives to prevent a pregnancy after unprotected sex is termed emergency contraception.

In common parlance, the term "abortion" is synonymous with induced abortion of a human fetus

Incidence

Women from 27 nations reported the following reasons for seeking an induced abortion: ^[1]

• 25.5% – Want to postpone childbearing
• 21.3% – Cannot afford a baby
• 14.1% – Has relationship problem or partner does not want pregnancy
• 12.2% – Too young; parent(s) or other(s) object to pregnancy
• 10.8% – Having a child will disrupt education or job
•   7.9% – Want no (more) children
•   3.3% – Risk to fetal health
•   2.8% – Risk to mother's health
•   2.1% – Rape, incest, other

In many areas of the world, especially developing nations or where induced abortions are illegal, many women choose or are forced to perform abortions on themselves. These self-induced abortions are usually unsafe abortions as described by the World Health Organization. Furthermore, some abortions are induced because of societal pressures, such as stigma of disabled persons and similar eugenic ideals, societal and religious disapproval of single motherhood, insufficient economic support for families, or laws such as China's one-child policy. These policies and societal pressures can lead to sex-selective abortion and infanticide, which is illegal in most countries, but difficult to stop. Research in India suggests that between 1985 and 2005 as many as 10 million female fetuses have been aborted for reasons of sex-selection. ^[2]

Most physicians advise patients that approximately 20-25% of all conceptions end up as miscarraiges.

Forms of abortion

Spontaneous abortion

Main article: Miscarriage

Spontaneous abortions, generally referred to as miscarriages, occur when an embryo or fetus is lost due to natural causes. A miscarriage is spontaneous loss of the embryo or fetus before the 20th week of development. Spontaneous abortions after the 20th week are generally considered to be preterm deliveries. Most miscarriages occur very early in a pregnancy.

Other causes can be infection (of either the woman or the fetus), immune responses, or serious systemic diseases of the woman.

The risk for spontaneous abortion is greater in those with a history of more than three previous (known) spontaneous abortions, those who have had a previous induced abortion, those with systemic diseases, and in women over age 35.

A spontaneous abortion can also be caused by accidental trauma; intentional trauma to cause miscarriage is considered an induced abortion. Some governments have laws increasing the criminal liability of a person who causes a miscarriage during an assault or other violent crime.

Induced abortion

A pregnancy can be intentionally terminated in a number of ways. The manner selected depends chiefly upon the gestational age of the fetus, in addition to the legality, regional availability, and/or doctor-patient preference for specific procedures.

Chemical abortion

Main article: Chemical abortion

Effective in the first trimester of pregnancy, chemical, or non-surgical abortions comprise 10% of all abortions in the United States and Europe. The process begins with the administration of either methotrexate or mifepristone, followed by misoprostol. While misoprostol may also be used alone to induce abortion, the need for surgical intervention is slightly elevated to about 10%, compared to the 8% when medications are combined. When surgical intervention is necessary, primarily vacuum uterine aspiration is used.

Surgical abortion

In the first fifteen weeks, suction-aspiration or vacuum abortion are the most common methods, replacing the more risky dilation and curettage (D & C). Manual vacuum aspiration, or MVA abortion, consists of removing the fetus or embryo by suction using a manual syringe, while the Electric vacuum aspiration or EVA abortion method uses suction produced by an electric pump to remove the fetus or embryo. From the fifteenth week up until around the eighteenth week, a surgical dilation and evacuation (D & E) is used. D & E consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.

Dilation and suction curettage consists of emptying the uterus by suction using a different apparatus. Curettage refers to the cleaning of the walls of the uterus with a curette. Dilation and curettage (D & C) is a standard gynaecological procedure performed for a variety of reasons, such as examination.

As the fetus grows, other techniques must be used to induce abortion in the third trimester. Premature delivery of the human fetus can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with caustic solutions containing saline or urea. Very late abortions can be brought about by intact dilation and extraction (intact D & X), which requires the surgical decompression of the fetus's head before evacuation, and is sometimes termed "partial-birth abortion." A hysterotomy abortion, similar to a caesarian section but resulting in a terminated fetus, can also be used at late stages of pregnancy. Hysterotomy abortion can be performed vaginally, with an incision just above the cervix, in the late mid-trimester.

Other means of abortion

A number of herbs can be effective abortifacients. Using herbs in this way can cause serious side effects, including multiple organ failure and other serious injury, and are not recommended by physicians.^[3] Physical trauma to a pregnant woman's womb can cause an abortion. The severity of the impact required to cause an abortion carries high risk of injury, without necessarily inducing a miscarriage^[4]. Both accidental and deliberate abortions of this kind carry criminal liability in many countries.

Health effects

As with most surgical procedures, the most common surgical abortion methods carry the risk of potentially serious complications. These risks include: a perforated uterus, perforated bowel or bladder, septic shock, sterility, and death. The risk of complications increases depending upon how far the pregnancy has progressed.

It is difficult to accurately assess the risks of induced abortion due to a number of factors. These factors include wide variation in the quality of abortion services in different societies and among different socio-economic groups, a lack of uniform definitions of terms, and difficulties in patient follow-up and after-care. The degree of risk is also dependent upon the skill and experience of the practitioner; maternal age, health, and parity; gestational age; pre-existing conditions; methods and instruments used; medications used; the skill and experience of those assisting the practitioner; and the quality of recovery and follow-up care. A highly-skilled practitioner, operating under ideal conditions, will tend to have a very low rate of complications; an inexperienced practitioner in an ill-equipped and ill-staffed facility, on the other hand, will often have a higher incidence of complications. Practitioners do not agree on the best methods of mitigating such risks.

In the United Kingdom, the number of deaths due to legal abortion between the years of 1991 and 1993 was 5, as compared to the 9 deaths caused by ectopic pregnancy during the same time frame. ^[5] In the United States, during the year 1999, there were a total of 4 deaths due to legal abortion. ^[6]

Use of other methods (e.g., overdose of various drugs, insertion of various objects into uterus) for abortion is potentially dangerous, carrying a significantly elevated risk for permanent injury or death compared to abortions done by physicians.

Some practitioners advocate using minimal anaesthesia so that the patient can alert them to possible complications. Others recommend general anaesthesia, in order to prevent patient movement, which might cause a perforation. General anaesthesia carries its own risks, including death, which is why public health officials recommend against its routine use.

Dilation of the cervix carries the risk of cervical tears or perforations, including small tears that might not be apparent and might cause cervical incompetence in future pregnancies. Most practitioners recommend using the smallest possible dilators, and using osmotic rather than mechanical dilators after the first trimester of pregnancy.

Instruments are placed within the uterus to remove the fetus. These can, on rare occassions, cause perforation or laceration of the uterus, and damage to structures surrounding the uterus. Laceration or perforation of the uterus or cervix can, again on rare occassions, lead to even more serious complications.

Incomplete emptying of the uterus can cause hemorrhage and infection. Use of ultrasound verification of the location and duration of the pregnancy prior to abortion, with immediate follow-up of patients reporting continuing pregnancy symptoms after the procedure, will virtually eliminate this risk. The sooner a complication is noted and properly treated, the lower the risk of permanent injury or death.

In rare cases, the abortion will be unsuccessful and the pregnancy will continue. An unsuccessful abortion can also result in the delivery of a live neonate, or infant. This, termed a failed abortion, is more likely to occur if the procedure is carried out later in the pregnancy. Some doctors faced with this situation have voiced concerns about the ethical and legal ramifications of then letting the neonate die. As a result, recent investigations have been launched in the United Kingdom by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the Royal College of Obstetricians and Gynaecologists, in order to determine how widespread the problem is and what an ethical response in the treatment of the infant might be. ^[7]

Suggested effects

There is controversy over a number of proposed risks and effects of abortion. Evidence, whether in support of or against such claims, might in part be influenced by the political and religious beliefs of the parties behind it.

Breast cancer

Main article: Abortion-breast cancer (ABC) hypothesis

The abortion-breast cancer (ABC) hypothesis posits a causal relationship between having an induced abortion and a higher risk of developing breast cancer in the future. An increased level of estrogen in early pregnancy helps to initiate cellular differentiation (growth) in the breast in preparation for lactation. If this process is terminated, through abortion, before full differentiation in the third trimester, then more "vulnerable" undifferentiated cells will be left than there were prior to the pregnancy. It is proposed that this might result in an elevated risk of breast cancer. The majority of interview-based studies have indicated a link, and some have been demonstrated to be statistically significant, ^[8] but there remains debate as to their reliability because of possible response bias.

Larger and more recent record-based studies, such as one in 1997 which used data from two national registries in Denmark, found the correlation to be negligible to non-existent after statistical adjustment. ^[9] The National Cancer Institute conducted an official workshop with dozens of experts on the issue, between February 24-26, 2003, which concluded from its examination of various evidence that it is "well established" that "induced abortion is not associated with an increase in breast cancer risk." ^[10] These findings and how the Denmark study statistically adjusted their overall results have been disputed by Dr. Joel Brind, ^[11] an invitee to the workshop and the leading scientific advocate of the abortion-breast cancer hypothesis. Nevertheless, gaps and inconsistencies remain in the research, and the subject continues to be one of political and scientific contention.

Fetal pain

Main article: Fetal pain

The experience of the fetus during abortion is a matter of medical, ethical and public policy concern. Evidence is conflicting, with some authorities holding that the fetus is capable of feeling pain from the first trimester, and others maintaining that the neuro-anatomical requirements for such experience do not exist until the second or third trimester.

Pain receptors begin to appear in the seventh week of pregnancy. The thalamus, the part of the brain which receives signals from the nervous system and then relays them to the cerebral cortex, starts to form in the fifth week. However, other anatomical structures involved in the nociceptic process are not present until much later in gestation. Links between the thalamus and cerebral cortex aren't forged until around the 23rd week. ^[12] Myelin, an insulation on nerve fibres whichs aids in the conduction of electrical impulses, does not begin to develop until the sixth month. ^[13]

Researchers have observed changes in the heart rates and hormonal levels of neonates after circumcision, blood tests, and surgery — effects which were alleviated with the administration of anaesthesia. ^[14] Others suggest that the human experience of pain, being more than just physiological, cannot be measured in such reflexive responses.

Mental health

Some women will experience negative feelings as a result of elective abortion. However, whether this phenomenon is significant enough to warrant a general diagnosis, or even classification as an independent syndrome (see post-abortion syndrome), is a subject that is debated among members of the medical community.

Data on the incidence of clinical depression, mental illness, post-traumatic stress disorder, and suicide in association with abortion remain inconclusive. ^[15] A comparative analysis of the suicide rates among postpartum and post-abortive women in Finland found a statistical correlation between abortion and suicide. ^[16] Other studies have suggested a link between the elective termination of an unwanted pregnancy and an improvement in reported mental well-being. The majority of evidence would seem to indicate that adverse emotional reactions to the procedure are most strongly influenced by pre-existing psychological conditions and other negative factors. ^[17]

Elective abortion may reduce the occurrence of depression in cases of unwanted pregnancy, as compared to cases in which the pregnancy has been carried to completion, but it is also sometimes reported as an additional stressor.

Spontaneous abortion, or miscarriage, is known to present an increased risk of depression in women. ^[18]

History of abortion

Main article: History of abortion

Bottom-most: "Dr. Caton's Tansy Pills!" An example of a clandestine advertisement.

The practice of induced abortion, according to some anthropologists, can be traced to ancient times. There is evidence to suggest that, historically, pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques.

Soranus, a 2nd century Greek physician, suggested in his work Gynaecology that women wishing to abort their pregnancies should engage in violent exercise, energetic jumping, carrying heavy objects, and riding animals. He also prescribed a number of recipes for herbal bathes, pessaries, and bloodletting, but advised against the use of sharp instruments to induce miscarriage due to the risk of organ perforation. ^[19] It is also known that the ancient Greeks relied upon the herb silphium as both a contraceptive and an abortifacient. The plant, as the chief export of Cyrene, was driven to extinction, but it is suggested that it might have possessed the same abortive properties as some of its closest extant relatives in the Apiaceae family.

Such folk remedies, however, varied in effectiveness and were not without risk. Tansy and pennyroyal, for example, are two poisonous herbs with serious side effects that have at times been used to terminate pregnancy.

19th-century medicine saw advances in the fields of surgery, anaesthesia, and sanitation, in the same era that doctors with the American Medical Association lobbied for bans on abortion in The United States and the British Parliament passed the Offences Against the Person Act. Demand for the procedure continued, however, as the disguised, but nonetheless open, advertisement of abortion services in Victorian times would seem to suggest. ^[20]

Abortion debate

Main article: Abortion debate

Over the course of the history of abortion, induced abortions have been a source of considerable debate and controversy regarding the morality and legality of this practice. An individual's position on the complex ethical, moral, philosophical, biological, and legal issues have a strong relationship with that individual's value system. A person's position on abortion may be best described as a combination of their personal beliefs on the morality of induced abortion, and that person's beliefs on the ethical scope and responsibility of legitimate governmental and legal authority. Another factor for many individuals is religious doctrine. See religion and abortion for more.

Abortion debates, especially pertaining to abortion laws, are often spearheaded by advocacy groups belonging to one of two camps. Most often those in favor of legal prohibition of abortion describe themselves as pro-life while those against legal restrictions on abortion describe themselves as pro-choice. Both are used to indicate the central principles in arguments for and against abortion: "Is the fetus a human being with a fundamental right to life?" for pro-life advocates, and, for those who are pro-choice, "Should the state or the individual have choice on the matter of abortion?"

In both public and private debate, arguments presented in favour of or against abortion focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Arguments on morality and legality tend to collide and combine, complicating the issue at hand.

Public opinion

Political sides have largely been divided into absolutes. The abortion debate, as such, tends to center around individuals who hold strong positions. However, public opinion varies from poll to poll, country to country, and region to region:

• Australia: In a February 2005 AC Nielsen poll, as reported in the The Age, 56% thought the current abortion laws, which generally allow abortion for the sake of life or health, were "about right," 16% want changes in law to make abortion "more accessible," and 17% want changes to make it "less accessible." ^[21] A 1998 poll, conducted by Roy Morgan Research, asked, "Do you approve of the termination of unwanted pregnancies through surgical abortion?" 65% of the Australians polled stated that they approved of surgical abortion and 25% stated that they disapproved of it. ^[22]

• Canada: A recent poll of Canadians, conducted in April 2005 by Gallup, found that 52% of those polled want abortion laws to "remain the same," 20% want the laws to be "less strict," and 24% would prefer that the laws become "more strict." An earlier Gallup poll, from December 2001, asked, "Do you think abortions should be legal under any circumstances, legal only under certain circumstances or illegal in all circumstances and in what circumstances?" 32% of Canadians responded that they believe abortion should be legal in all circumstance, 52% that it should be legal in certain circumstances, and 14% that it should be legal in no circumstances. See Abortion in Canada.

• Ireland: A 1997 Irish Times/MRBI poll of the Republic of Ireland's electorate found that 18% believe that abortion should never be permitted, 35% that one should be allowed in the event that the woman's life is threatened, 18% if her health is at risk, 28% that "an abortion should be provided to those who need it," and 5% were undecided. ^[23]

• The United Kingdom: An online YouGov/Daily Telegraph poll in August 2005 found that 30% of Britons would back a measure to reduce the legal limit for abortion to 20 weeks, 19% support a limit of 12 weeks, 9% support a limit of less than 12 weeks, and 25% support maintaining the current limit of 24 weeks. 6% responded that abortion should never be allowed while 2% said it should be permitted throughout the entirety of pregnancy. ^[24]

• The United States: In a January 2006 CBS News poll, which asked, "What is your personal feeling about abortion?", 27% of Americans said that abortion should be "permitted in all cases," 15% that it should be "permitted, but subject to greater restrictions than it is now," 33% that it should be "permitted only in cases such as rape, incest or to save the woman's life," 17% that it should "only be permitted to save the woman's life," and 5% that it should "never" be permitted.

Abortion law

Main article: Abortion law

International status of abortion law

File:PBAsigning wide.jpg

U.S. President George W. Bush signs the Partial-Birth Abortion Ban Act of 2003

The Soviet Union (1920) and Iceland (1935) were some of the first countries to generally allow abortion. The second half of the twentieth century saw the liberalization of abortion laws in many other countries. In 1973, the U.S. Supreme Court struck down state laws banning abortion, ruling that such laws violated an inferred right to privacy in the U.S. Constitution. The Supreme Court of Canada, similarly, discarded its criminal code regarding abortion in 1988, after ruling that such restrictions violated the security of person guaranteed to women under in the Canadian Charter of Rights and Freedoms in the case of R. v. Morgentaler. Canada later struck down provincial regulations of abortion in the case of R. v. Morgentaler (1993). Ireland, on the other hand, added an amendment to its Constitution in 1983 by popular referendum, recognizing "the right to life of the unborn." (see Abortion in Ireland).

Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, and the right to security of person are major issues of human rights that are sometimes used as justification for the existence or the absence of laws controlling abortion. Many countries in which abortion is legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using a trimester-based system to regulate the window in which abortion is still legal to perform:

• In the United States, some states impose a 24-hour waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion.
• In the United Kingdom, as in some other countries, two doctors must first certify that an abortion is medically or socially necessitated before it can be performed.

Other countries, in which abortion is illegal, will allow one to be performed in the case of rape, incest, or danger to the pregnant woman's life or health. A handful of nations ban abortion entirely, such as Chile, El Salvador, and Malta.

See also

• Abortion in Canada
• Abortion in the Republic of Ireland
• Abortion in the United Kingdom
• Abortion in the United States
• Adoption
• Partial-birth abortion
• Pregnancy
• Religion and abortion
• Selective reduction
• Self-induced abortion
• Sex-selective abortion and infanticide
• Wrongful abortion

Sources

1. ^ Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries." International Family Planning Perspectives, 1998
2. ^ Reaney, Patricia. (2006, January 9). "Selective abortion blamed for India's missing girls." Reuters AlertNet. Retrieved January 9, 2006.
3. ^ Ciganda C, Laborde A., "Herbal infusions used for induced abortion", J Toxicol Clin Toxicol. 2003; 41(3):235-9
4. ^ Education for Choice. (2005, May 6). Unsafe abortion. Retrieved January 11, 2006.
5. ^ Department of Health. (1998). Why Mothers Die: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–1996. London: The Stationery Office. Retrieved January 11, 2006.
6. ^ Elam-Evans, Laurie. D., Strauss, Lilo T., Herndon, Joy, Parker, Wilda Y., Bowens, Sonya V., Zane, Suzanne, et al. Centers for Disease Control and Prevention. (2003, November 23). Abortion Surveillance - United States, 2000. Morbidity and Mortality Weekly Report. Retrieved January 11, 2006.
7. ^ Rogers, Lois. (2005, November 27). "Fifty babies a year are alive after abortion." The Sunday Times. Retrieved January 11, 2006.
8. ^ American abortion-breast cancer studies
9. ^ Melbye M., Wohlfahrt, J., Olsen, J.H., Frisch, M., Westergaard, T., Helweg-Larsen, K., et al. (1997). Induced abortion and the risk of breast cancer [Electronic version]. New England Journal of Medicine, 336, 81-5. Retrieved January 11, 2006 from PubMed.
10. ^ National Cancer Institute. (2003, March 4). Summary Report: Early Reproductive Events and Breast Cancer Workshop. Retrieved January 11, 2006.
11. ^ National Cancer Institute. (2003). Minority Dissenting Comment Regarding Early Reproductive Events and Breast Cancer Workshop. Retrieved January 11, 2006.
12. ^ Parliamentary Office of Science and Technology. (1997). Fetal Awareness. Retrieved January 11, 2006.
13. ^ Mulligan LaRossa, Maureen, & Carter, Sheena L. (2005, February 7). Understanding How the Brain Develops. Retrieved January 11, 2006, from Emory University, Department of Pediatrics web site: [25].
14. ^ Anand, K., Phil, D., & Hickey, P.R. (1987). Pain and its effects on the human neonate and fetus [Electronic version]. New England Journal of Medicine, 316 (21), 1321-9. Retrieved January 11, 2006.
15. ^ Schmiege, S. & Russo, N.F. (2005). Depression and unwanted first pregnancy: longitudinal cohort study [Electronic version] . British Medical Journal, 331 (7528), 1303. Retrieved January 11, 2006.
16. ^ Gissler, M., Hemminki, E., & Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987-94: register linkage study [Electronic version]. British Medical Journal, 313, 1431-4. Retrieved January 11, 2006.
17. ^ American Psychological Association. (2005). APA Briefing Paper on The Impact of Abortion on Women. Retrieved January 11, 2006 from Google cache.
18. ^ Depression Risk Increased After Miscarriage. (2002, April 1). Retrieved January 11, 2006.
19. ^ Lefkowitz, Mary R. & Fant, Maureen R. (1992). Women's life in Greece & Rome: a source book in translation. Baltimore, MD: John Hopkins University Press. Retrieved January 11, 2006.
20. ^ Histories of Abortion. (n.d.) Retrieved January 11, 2006.
21. ^ Grattan, Michelle. (2005, February 16). "Poll backs abortion laws." The Age. Retrieved January 11, 2006.
22. ^ Roy Morgan International. (1998, March 3). Almost Two-Thirds Of Australians Approve Of Abortion. Retrieved January 11, 2006.
23. ^ Kennedy, Geraldine. (1997, December 11). "77% say limited abortion right should be provided." The Irish Times. Retrieved January 11, 2006.
24. ^ YouGov. (2005, July 30). YouGov/Daily Telegraph Survey Results. Retrieved January 11, 2006.
25. ^ The Polling Report. (2006). Retrieved January 11, 2006.

External links

• Abortion Statistics and Other Data
• Abortion Laws of the World
• Abortion Policies: A Global Review

The following links may be biased:

• Abortion.com
• The Alan Guttmacher Institute
• American Life League
• CareNet
• Just Facts: Abortion
• Planned Parenthood
• Center for Bio-Ethical Reform