Abortion

An abortion is the termination of a pregnancy associated with the death of an embryo or a fetus, in other words a living child, a baby. In medicine, the following terms are used to define an abortion:

Spontaneous abortion: An abortion due to accidental trauma or natural causes, this is commonly termed a miscarriage.
Induced abortion: Induced abortions are further subcategorized into therapeutic abortions (how is it therapeutic to directly kill the unborn child?) and elective (on demand) abortions.
- Therapeutic abortion: An abortion performed because the pregnancy poses physical or mental health risk (says who, the abortionist?) to the pregnant woman.
- Elective abortion: An abortion performed for any other reason, that is, for convenience sake.

In common parlance, the term "abortion" is synonymous with induced abortion.

A pregnancy that terminates early, but where the fetus survives to become a live infant, is instead termed a premature birth. A pregnancy that ends with an infant dead upon birth, due to causes such as spontaneous abortion or complications during delivery, is termed a stillbirth. Certain forms of birth control are used to prevent implantation before the pregnancy occurs. These acts of emergency contraception are not classified as abortion by medicine, due to a pro-legalized abortion stance.

The ethics and morality of induced abortion have become the subject of an intense debate in the past 50 years in various areas of the world, particularly in the United States of America, but also to a lesser extent in Canada and a number of countries in Europe.

Any female mammal can experience abortion, however this article focuses exclusively on abortion in women.

Spontaneous abortion

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 preterm deliveries. Up to 78% of all conceptions may fail, in most cases even before pregnancy is confirmed. 15% of all confirmed pregnancies end in a miscarriage. Most miscarriages occur very early in a pregnancy.

Early embryonic development is an error prone process, and the body may spontaneously abort if a fetus is not viable (i.e., due to genetic deformities, such as most cases of trisomy), or when the womb is unable to support the development of the fetus. Other causes can be infection (of either the mother or the fetus), immune responses, or serious systemic diseases of the mother.

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

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

Induced abortions

The term "abortion" is usually used by lay people to refer to induced abortion. 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 the developing nations or where induced abortions are illegal, many women choose or are pushed to perform abortions on themselves. These self-induced abortions are commonly 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 under 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.

Methods of inducing abortion

Depending on the gestational age of the embryo or fetus, different methods of abortion can be performed to remove the embryo or fetus from the womb.

Medical Abortion

Effective in the first trimester of pregnancy, medical, 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 the controversial intact dilation and extraction (intact D & X) which requires the surgical decompression of the fetus's head before evacuation and is controversially 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.

An attempted abortion which results in the expulsion of a live infant is termed a failed abortion. A failed abortion is more likely to occur later in pregnancy. Some doctors who have induced a failed abortion have faced the prospect of having to kill the resulting infant, but are voicing concern that doing so is perhaps bad medicine and may subject them to criminal sanctions. As a result, recent investigations have been launched in England by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the Royal College of Obstetricians and Gynaecologists to determine how widespread the concern is and how to address it. ^[2]

Other means of abortion

A number of herbs are 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. Both accidental and deliberate abortions of this kind carry criminal liability in many countries.^[4]

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.

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.

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

Physical health

Each phase of the abortion carries separate risks, and practitioners are not in agreement as to the best methods of mitigating those risks. The degree of risk depends 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.

Some practitioners advocate using the minimal possible anesthesia, so that patient pain can alert the practitioner to possible complications. Others recommend general anesthesia in order to prevent patient movement which might cause a perforation. General anesthesia carries its own risks and most public health officials recommend against its routine use in abortion due to an increased risk of death.

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. In rare cases, the abortion will be unsuccessful and the pregnancy will continue. Most practitioners recommend a second procedure to terminate the pregnancy due to the possibility that the abortion attempt had caused injury to the fetus.

The sooner a complication is noted and properly treated, the lower the risk of permanent injury or death.

A specific and undisputed complication that can arise, especially with repeated abortions by a dilatation and curettage, is the development of Asherman syndrome.

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 affiliations of the parties behind it.

Breast cancer

The controversial abortion-breast cancer (ABC) hypothesis posits an association between having an abortion and a higher risk of developing breast cancer. The proposed mechanism is based on the increased estrogen levels found during early pregnancy, which initiate cellular differentiation (growth) in the breast in preparation for lactation. The ABC hypothesis states that if the pregnancy is aborted before full differentiation in the third trimester, then more "vulnerable" undifferentiated cells would be left than prior to the pregnancy, resulting 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, but there remains debate as to their reliability because of possible response bias.

According to the National Cancer Institute (NCI), it is "well established" that "induced abortion is not associated with an increase in breast cancer risk." Those findings have been disputed by Dr. Joel Brind, a leading scientific advocate of the ABC hypothesis. Nevertheless, gaps and inconsistencies remain in the research as the "ABC link" continues to be a politicized issue.

Fetal pain

The experience of the fetus during abortion is a matter of consideration among scientists and political activists. Evidence is conflicting, with some authorities claiming that the fetus is capable of feeling pain from the first trimester, while others hold 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. [5]. Myelin, an insulation on nerve fibres whichs aids in the conduction of electrical impulses, does not begin to develop until the sixth month. [6]

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. [7] Others suggest that the human experience of pain, being more than just physiological, cannot be measured in such reflexive responses.

Mental health

It is indisputable that 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 abortion trauma 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. [8] A comparative analysis of the suicide rates among postpartum and post-abortive women in Finland found a raw statistical correlation between abortion and suicide. [9] 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. [10]

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, presents an increased risk of depression in women. [11]

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. [12] 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. [13]

The abortion debate

Throughout 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 centre 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 were "about right," 16% want changes in law to make abortion "more accessible," and 17% want changes to make it "less accessible." [14] 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. [15]

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 mother'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. [16]

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.

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. [17]

The United States: A CNN/USA Today/Gallup poll conducted in November 2005 revealed that 39% believe that abortion should be legal only in "a few circumstances" and another 16% think that it should be legal under "no circumstances", whereas 26% believe it should remain legal in "all circumstances" (the current law under Roe v. Wade) and 16% said it should be legal under "most circumstances". [18] Additional recent U.S. polling data can be found here. [19]

Abortion law

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, controversially 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. 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.

Sources

^ Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries." International Family Planning Perspectives, 1998
^ Moreau, C. et al, "Previous induced abortions and the risk of very preterm delivery", BJOG. 2005; 112(4):430-7
^ The Sunday Times (Britain) November 27, 2005
^ http://news.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/15/nabort15.xml
^ Beral V, Bull D, Doll R, Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83?000 women with breast cancer from 16 countries. Lancet. 2004 Mar 27;363(9414):1007-16. PMID 15051280
^ Ciganda C, Laborde A., "Herbal infusions used for induced abortion", J Toxicol Clin Toxicol. 2003; 41(3):235-9
^ Education For Choice – Unsafe abortion

External links

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