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Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus.[nb 1] An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of all pregnancies.[2][3] When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion.[4][5] The most common reasons women give for having an abortion are for birth-timing and limiting family size.[6][7][8] Other reasons reported include maternal health, an inability to afford a child, domestic violence, lack of support, feeling they are too young, wishing to complete education or advance a career, and not being able or willing to raise a child conceived as a result of rape or incest.[6][8][9]
| Abortion | |
|---|---|
| Other names | Induced miscarriage, termination of pregnancy |
| Specialty | Obstetrics and gynecology |
| ICD-10-PCS | 10A0 |
| ICD-9-CM | 779.6 |
| MeSH | D000028 |
| MedlinePlus | 007382 |
| eMedicine | 252560 |
When done legally in industrialized societies, induced abortion is one of the safest procedures in medicine.[10]: 1 [11] Unsafe abortions—those performed by people lacking the necessary skills, or in inadequately resourced settings—are responsible for between 5–13% of maternal deaths, especially in the developing world.[12] However, medication abortions that are self-managed are highly effective and safe throughout the first trimester.[13][14][15] Public health data show that making safe abortion legal and accessible reduces maternal deaths.[16][17]
Modern methods use medication or surgery for abortions.[18] The drug mifepristone (aka RU-486) in combination with prostaglandin appears to be as safe and effective as surgery during the first and second trimesters of pregnancy.[18][19] The most common surgical technique involves dilating the cervix and using a suction device.[20] Birth control, such as the pill or intrauterine devices, can be used immediately following abortion.[19] When performed legally and safely on a woman who desires it, induced abortions do not increase the risk of long-term mental or physical problems.[21] In contrast, unsafe abortions performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities cause between 22,000 and 44,000 deaths and 6.9 million hospital admissions each year.[22] The World Health Organization states that "access to legal, safe and comprehensive abortion care, including post-abortion care, is essential for the attainment of the highest possible level of sexual and reproductive health".[23] Historically, abortions have been attempted using herbal medicines, sharp tools, forceful massage, or other traditional methods.[24]
Around 73 million abortions are performed each year in the world,[25] with about 45% done unsafely.[26] Abortion rates changed little between 2003 and 2008,[27] before which they decreased for at least two decades as access to family planning and birth control increased.[28] As of 2018[update], 37% of the world's women had access to legal abortions without limits as to reason.[29] Countries that permit abortions have different limits on how late in pregnancy abortion is allowed.[30] Abortion rates are similar between countries that restrict abortion and countries that broadly allow it, though this is partly because countries which restrict abortion tend to have higher unintended pregnancy rates.[31]
Globally, there has been a widespread trend towards greater legal access to abortion since 1973,[32] but there remains debate with regard to moral, religious, ethical, and legal issues.[33][34] Those who oppose abortion often argue that an embryo or fetus is a person with a right to life, and thus equate abortion with murder.[35][36] Those who support abortion's legality often argue that it is a woman's reproductive right.[37] Others favor legal and accessible abortion as a public health measure.[38] Abortion laws and views of the procedure are different around the world. In some countries abortion is legal and women have the right to make the choice about abortion.[39] In some areas, abortion is legal only in specific cases such as rape, incest, fetal defects, poverty, and risk to a woman's health.[40]
Induced
An induced abortion is a medical procedure to end a pregnancy.[41] In modern English, the term abortion, when used without further qualification, generally refers to induced abortion.[5]
A pregnancy can be intentionally aborted in several ways. The abortion method depends upon the gestational age of the embryo or fetus, which gains mass as the pregnancy progresses.[42][43] Abortion laws, regional availability, and the personal preference of the women and her doctor may inform the women's choice of a specific abortion procedure.
Abortions can be characterized as either therapeutic or elective. When an abortion is performed for medical reasons, the procedure is referred to as a therapeutic abortion. Medical reasons for therapeutic abortion include saving the life of the pregnant woman, preventing harm to the woman's physical or mental health, preventing the birth of a child who will have a significantly increased chance of mortality or morbidity, and reducing the number of fetuses to lessen health risks associated with multiple pregnancy.[44][45] An abortion is referred to as elective or voluntary when it is performed at the request of the woman for non-medical reasons.[45] Confusion sometimes arises over the term elective because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.[46]
About one in five pregnancies worldwide ends with an induced abortion.[27] Most abortions result from unintended pregnancies.[6][47] In the United Kingdom, 1 to 2% of abortions are done because of genetic problems in the fetus.[21]
Spontaneous
Miscarriage, also known as spontaneous abortion, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.[48] A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is a "premature birth" or a "preterm birth".[49] When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".[50] Premature births and stillbirths are generally not considered to be miscarriages, although usage of these terms can sometimes overlap.[51]
Studies of pregnant women in the US and China have shown that between 40% and 60% of embryos do not progress to birth.[52][53][54] The vast majority of miscarriages occur before the woman is aware that she is pregnant,[45] and many pregnancies spontaneously abort before medical practitioners can detect an embryo.[55] Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.[56] 80% of these spontaneous abortions happen in the first trimester.[57]
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus,[45][58] accounting for at least 50% of sampled early pregnancy losses.[59] Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.[58] Advancing maternal age and a woman's history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.[59] A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.[60]
Medical
Practice of Induced Abortion Methods
Induced Miscarr.
Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486) in the 1980s.[19][18][61][62]
The most common early first trimester medical abortion regimens use mifepristone in combination with misoprostol (or sometimes another prostaglandin analog, gemeprost) up to 10 weeks (70 days) gestational age,[63][64] methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.[18] Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone, particularly in the second trimester.[61][65] Medical abortion regimens involving mifepristone followed by misoprostol in the cheek between 24 and 48 hours later are effective when performed before 70 days' gestation.[64][63]
In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.[66] Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age; from 9 to 10 weeks efficacy decreases modestly to 94%.[63][67] If medical abortion fails, surgical abortion must be used to complete the procedure.[68]
Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain,[69] France,[70] Switzerland,[71] United States,[72] and the Nordic countries.[73]
Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second trimester abortions in Canada, most of Europe, China and India,[62] in contrast to the United States where 96% of second trimester abortions are performed surgically by dilation and evacuation.[74]
A 2020 Cochrane Systematic Review concluded that providing women with medications to take home to complete the second stage of the procedure for an early medical abortion results in an effective abortion.[75] Further research is required to determine if self-administered medical abortion is as safe as provider-administered medical abortion, where a health care professional is present to help manage the medical abortion.[75] Safely permitting women to self-administer abortion medication has the potential to improve access to abortion.[75] The review also noted a research gap concerning methods to support women who take medication at home for a self-administered abortion.[75]
Surgical
.svg)
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump
Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion.[76] Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump. Both techniques can be used very early in pregnancy. MVA can be used up to 14 weeks but is more often used earlier in the U.S. EVA can be used later.[74]
MVA, also known as "mini-suction" and "menstrual extraction", or EVA can be used in very early pregnancy when cervical dilation may not be required. Dilation and curettage (D&C) refers to opening the cervix (dilation) and removing tissue (curettage) via suction or sharp instruments. D&C is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The World Health Organization recommends sharp curettage only when suction aspiration is unavailable.[77]
Dilation and evacuation (D&E), used after 12 to 16 weeks, consists of opening the cervix and emptying the uterus using surgical instruments and suction. D&E is performed vaginally and does not require an incision. Intact dilation and extraction (D&X) refers to a variant of D&E sometimes used after 18 to 20 weeks when removal of an intact fetus improves surgical safety or for other reasons.[78]
Abortion may also be performed surgically by hysterotomy or gravid hysterectomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and can be used during later stages of pregnancy. Gravid hysterectomy refers to removal of the whole uterus while still containing the pregnancy. Hysterotomy and hysterectomy are associated with much higher rates of maternal morbidity and mortality than D&E or induction abortion.[79]
First trimester procedures can generally be performed using local anesthesia, while second trimester methods may require deep sedation or general anesthesia.[80][81][82]
Labor induction abortion
In places lacking the necessary medical skill for dilation and extraction, or when preferred by practitioners, an abortion can be induced by first inducing labor and then inducing fetal demise if necessary.[83] This is sometimes called "induced miscarriage". This procedure may be performed from 13 weeks gestation to the third trimester. Although it is very uncommon in the United States, more than 80% of induced abortions throughout the second trimester are labor-induced abortions in Sweden and other nearby countries.[84]
Only limited data are available comparing labor-induced abortion with the dilation and extraction method.[84] Unlike D&E, labor-induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth. For this reason, labor-induced abortion is legally risky in the United States.[84][85]
Other methods
Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine. Such herbs include tansy, pennyroyal, black cohosh, and the now-extinct silphium.[86]: 44–47, 62–63, 154–155, 230–231
In 1978, one woman in Colorado died and another developed organ damage when they attempted to terminate their pregnancies by taking pennyroyal oil.[87] Because the indiscriminant use of herbs as abortifacients can cause serious—even lethal—side effects, such as multiple organ failure,[88] such use is not recommended by physicians.
Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.[89] In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.[90] One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.[90]
Reported methods of unsafe, self-induced abortion include misuse of misoprostol and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These and other methods to terminate pregnancy may be called "induced miscarriage". Such methods are rarely used in countries where surgical abortion is legal and available.[91]
The health risks of abortion depend principally on how, and under what conditions, the procedure is performed. The World Health Organization (WHO) defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities.[92] Legal abortions performed in the developed world are among the safest procedures in medicine.[10][93] According to a 2012 study in Obstetrics & Gynecology, in the United States the risk of maternal mortality is 14 times lower after induced abortion than after childbirth.[94] The CDC estimated in 2019 that US pregnancy-related mortality was 17.2 maternal deaths per 100,000 live births,[95] while the US abortion mortality rate was 0.43 maternal deaths per 100,000 procedures.[11][96][97] In the UK, guidelines of the Royal College of Obstetricians and Gynaecologists state that "Women should be advised that abortion is generally safer than continuing a pregnancy to term."[98] Worldwide, on average, abortion is safer than carrying a pregnancy to term. A 2007 study reported that "26% of all pregnancies worldwide are terminated by induced abortion," whereas "deaths from improperly performed [abortion] procedures constitute 13% of maternal mortality globally."[99] In Indonesia in 2000 it was estimated that 2 million pregnancies ended in abortion, 4.5 million pregnancies were carried to term, and 14–16 percent of maternal deaths resulted from abortion.[100]
In the US from 2000 to 2009, abortion had a mortality rate lower than plastic surgery, lower or similar to running a marathon, and about equivalent to traveling 760 miles (1,220 km) in a passenger car.[11] Five years after seeking abortion services, women who gave birth after being denied an abortion reported worse health than women who had either first or second trimester abortions.[101] The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth.[102] Outpatient abortion is as safe from 64 to 70 days' gestation as it before 63 days.[103]
Safety of abortion methods
There is little difference in terms of safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 10 weeks gestation.[66] Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.[104][105]
Safety and gestational age
Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications, which are rare, can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.[106] Infections account for one-third of abortion-related deaths in the United States.[107] The rate of complications of vacuum aspiration abortion in the first trimester is similar regardless of whether the procedure is performed in a hospital, surgical center, or office.[108] Preventive antibiotics (such as doxycycline or metronidazole) are typically given before abortion procedures,[109] as they are believed to substantially reduce the risk of postoperative uterine infection;[80][110] however, antibiotics are not routinely given with abortion pills.[111] The rate of failed procedures does not appear to vary significantly depending on whether the abortion is performed by a doctor or a mid-level practitioner.[112]
Complications after second trimester abortion are similar to those after first trimester abortion, and depend somewhat on the method chosen.[113] The risk of death from abortion approaches roughly half the risk of death from childbirth the farther along a woman is in pregnancy; from one in a million before 9 weeks gestation to nearly one in ten thousand at 21 weeks or more (as measured from the last menstrual period).[114][115] It appears that having had a prior surgical uterine evacuation (whether because of induced abortion or treatment of miscarriage) correlates with a small increase in the risk of preterm birth in future pregnancies. The studies supporting this did not control for factors not related to abortion or miscarriage, and hence the causes of this correlation have not been determined, although multiple possibilities have been suggested.[116][117]
Mental health
Current evidence finds no relationship between most induced abortions and mental health problems[21][118] other than those expected for any unwanted pregnancy.[119] A report by the American Psychological Association concluded that a woman's first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term; the mental-health outcome of a woman's second or greater abortion is less certain.[119][120] Some older reviews concluded that abortion was associated with an increased risk of psychological problems;[121] however, later reviews of the medical literature found that previous reviews did not use an appropriate control group.[118] When a control group is utilized, receiving abortion is not associated with adverse psychological outcomes.[118] However, women seeking abortion who are denied access to abortion have an increase in anxiety after the denial.[118]
Although some studies show negative mental-health outcomes in women who choose abortions after the first trimester because of fetal abnormalities,[122] more rigorous research would be needed to show this conclusively.[123] Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", but this is not recognized by medical or psychological professionals in the United States.[124]
A 2020 long term-study among US women found that about 99% of women felt that they made the right decision five years after they had an abortion. Relief was the primary emotion with few women feeling sadness or guilt. Social stigma was a main factor predicting negative emotions and regret years later. The researchers also stated: "These results add to the scientific evidence that emotions about an abortion are associated with personal and social context, and are not a product of the abortion procedure itself."[125]
Safety in the abortion debate
Some purported risks of abortion are promoted primarily by anti-abortion groups,[126][127] but lack scientific support.[126] For example, the question of a link between induced abortion and breast cancer has been investigated extensively. Major medical and scientific bodies (including the WHO, National Cancer Institute, American Cancer Society, Royal College of OBGYN and American Congress of OBGYN) have concluded that abortion does not cause breast cancer.[128]
In the past even illegality has not automatically meant that the abortions were unsafe. Referring to the U.S., historian Linda Gordon states: "In fact, illegal abortions in this country have an impressive safety record."[129]: 25
According to Rickie Solinger,
A related myth, promulgated by a broad spectrum of people concerned about abortion and public policy, is that before legalization abortionists were dirty and dangerous back-alley butchers.... [T]he historical evidence does not support such claims.[130]: 4
A 1940s American physician spoke of his pride in having performed 13,844 illegal abortions without any fatalities.[131] In 1870s New York City, the abortionist/midwife Madame Restell (Anna Trow Lohman) is said to have lost very few women among her more than 100,000 patients[132]—a lower mortality rate than the childbirth mortality rate at the time. In 1936, obstetrics and gynecology professor Frederick J. Taussig wrote that a cause of increasing mortality during the years of illegality in the U.S. was that
With each decade of the past fifty years the actual and proportionate frequency of this accident [perforation of the uterus] has increased, due, first, to the increase in the number of instrumentally induced abortions; second, to the proportionate increase in abortions handled by doctors as against those handled by midwives; and, third, to the prevailing tendency to use instruments instead of the finger in emptying the uterus.[133]
Unsafe abortion
Women seeking an abortion may use unsafe methods, especially when abortion is legally restricted. They may attempt self-induced abortion or seek the help of a person without proper medical training or facilities. This can lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.[134]
Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.[10] Unsafe abortions are believed to result in millions of injuries.[10][135] Estimates of deaths vary according to methodology, and have ranged from 37,000 to 70,000 in the past decade;[10][136][137] deaths from unsafe abortion account for around 13% of all maternal deaths.[138] The World Health Organization believes that mortality has fallen since the 1990s.[139] To reduce the number of unsafe abortions, public health organizations have generally advocated emphasizing the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services.[140]
A major factor in whether abortions are performed safely or not is the legal standing of abortion. Countries with restrictive abortion laws have higher rates of unsafe abortion and similar overall abortion rates compared to countries where abortion is legal and available.[136][27] For example, the 1996 legalization of abortion in South Africa led to an immediate reduction in abortion-related complications,[141] with abortion-related deaths dropping by more than 90%.[142] Similar reductions in maternal mortality have been observed after other countries have liberalized their abortion laws, such as Romania and Nepal.[143] A 2011 study concluded that in the United States, some state-level anti-abortion laws are correlated with lower rates of abortion in that state.