eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Elective Abortion
Updated: Dec 22, 2008
Introduction
Background
In the United States and worldwide, elective termination of pregnancy remains common. Accurate statistics have been kept since the enactment of the 1973 US Supreme Court decisions legalizing abortions.
- Since the 1973 decision, approximately 1.3-1.4 million abortions have been performed annually in the United States.
- Abortion is one of the most common medical procedures performed in the United States each year.
- Medical termination of pregnancy with mifepristone was approved in the United States in 2000 and is used in 31 countries worldwide. Approximately half of all surgical abortions are performed with this method.
- More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
- Worldwide, some 20-30 million legal abortions are performed annually, with another 10-20 million abortions performed illegally (see The Alan Guttmacher Institute). Illegal abortions are unsafe and account for 13% of all maternal mortality and serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
- In spite of the introduction of newer, more effective, and more widely available contraceptive methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these pregnancies, approximately half end in elective terminations.
- Each year in the United States, almost 3% of all reproductive-aged women terminate their pregnancies. While women of every social class seek terminations, the typical woman who terminates her pregnancy is young, white, unmarried, and poor.
Legalization of Abortion
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of some medical personnel.
Since the landmark 1973 US Supreme Court decision legalizing abortion, hundreds of laws, federal and state, have been proposed or passed, making this the most actively litigated and highly publicized area in the field of medicine. Many of these laws are enjoined by court order and are thus not enforceable. They span a variety of controversial rulings, including provisions to establish viability before termination, parental or spousal notification, mandatory waiting periods, mandatory wording for counseling sessions, denial of public funding, denial of public funds for counseling (gag orders), targeted regulations specific to abortion providers, and provisions against specific abortion techniques.
Laws in several states mandate the examination of fetal tissue removed at the time of surgical abortion; how these laws will apply to medical abortions remains unclear. Because virtually all the laws regulating abortions were written before the legalization of medical abortions, some of these laws, such as the fetal tissue examination statutes, may be non sequiturs. Laws in some states criminalize these procedures, and performing a specific abortion constitutes a felony offense by the provider. Thirty-one states have forced parental consent or notification. Nine state courts block these laws. Thirty-one states ban abortion coverage for low-income women, and 19 states pay for abortion for low-income women.
Abortion politics even compromise access to emergency contraception thought to block implantation of a fertilized egg. Laws may be needed to protect victims of sexual assault. A pending bill in Maryland proposes that hospitals provide emergency contraception to all rape victims who seek treatment. However, the Maryland legislature adjourned in April of 2002 without passing this bill.
In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions. In states where the laws are very restrictive, a trend exists toward delaying abortion procedures until later gestational ages, which makes access to care harder to achieve and actually increases medical risk unnecessarily.
Before Roe v Wade
Before the 19th century, most US states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
The first US federal law on the subject was the notorious Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception to suppress the circulation of "obscene" materials. From 1900 until the 1960s, abortions were prohibited by law. However, the Kinsey report noted that premarital pregnancies were electively aborted, and public and clinician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and assured their right to autonomy in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.
Roe v Wade
Roe v Wade was the culmination of the work of a wide consortium of individuals and groups who collectively crafted a strategy to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL). Lawyers were committed to expediting universal access to rights at a time when states were slowly liberalizing pertinent laws. Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
In 1973, the Roe vs Wade law, in the opinion written by US Supreme Court judge Harry Blackmun (appointed by Richard Nixon), the court ruled that a woman had a right to induced abortion during the first 2 trimesters of pregnancy. He cited the safety of the procedures and the fundamental right of women to be free from the states' legislation concerning this inherently medical decision in the first trimester of pregnancy.
Blackmun sidestepped the question of viability of the pregnancy, specifically stating that scholars in many respected disciplines could not resolve this issue. Therefore, he felt that the court need not resolve this either. Since this ruling, the states have regained much control, and serious restrictions have been placed on abortion services. The Hyde amendment in 1976 prohibited the use of federal funds for abortions, except in the case of maternal life endangerment. Since then, an estimated one third of public funding recipients cannot obtain an abortion because of inability to pay for the service.
Viability determinations
Loosely defined, the term viability is the fetus' ability to survive extrauterine life with or without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation. However, there are no reliable or medically acceptable tests for this prior to 28 weeks' gestation.
The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (eg, anencephaly). In Colautti v Franklin, the court overturned a Pennsylvania law requiring physicians to follow specific directives in certain medical circumstances and recognized physician judgment as sacrosanct and important.
Parental consent
Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass. On February 12, 2002, the West Virginia Senate Health and Human Resources Committee passed a bill requiring women seeking an abortion to give informed consent and wait for at least 24 hours before undergoing the abortion procedure. Specifically, the women must be furnished with written material, printed by the state, that would outline alternatives to abortion and the potential risks of the procedure.
On February 21, 2002, the Kentucky Senate passed 2 abortion-related bills. Kentucky SB 151 makes the existing consent laws more rigorous by requiring a woman to meet with a provider in person to receive preabortion counseling. Given that women must travel to access services, these laws quickly become restrictive for low-income care recipients.
Sociologic research shows that a good portion of minors (persons <18 y) do involve their parents in their decision to abort (45%). However, these laws have fostered a new ominous trend, ie, minors obtaining abortions significantly later in their pregnancies and often traveling great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term "partial-birth abortion" loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This delineation is so overly broad that both legal and expert gynecologic testimony claim this definition encompasses virtually all methods of second-trimester abortion, including dilation and extraction and inductions.
In 19 US states, laws have banned these procedures; in only 8 US states are these laws enforced. In his first administration, US President Clinton vetoed 2 bills banning such abortions. The US Supreme Court ruled on June 28, 2000 that the Nebraska law and all other laws banning partial-birth abortion are unconstitutional. The reasons for the US Supreme Court's decision was that the Nebraska law did not contain an exception to protect the health of the mother, and the law was also thought to "unduly burden" a woman's choice to end her own pregnancy.
Recently, the US Department of Justice filed an amicus brief, on behalf of the Bush administration, asking the Sixth US Circuit Court of Appeals to reverse a decision by a lower court, which struck down the Ohio ban on late-term abortions. This ban was struck down by US District Court Judge Walter Rice because the legislation does not allow for the procedure when a woman's life is in danger.
Similarly, in Stenberg v Carhart, the US Supreme Court struck down Nebraska's ban on late-term abortions for the same reason, ie, because it may be necessary if a woman's life is in danger. However, the US Department of Justice states the Ohio ban is constitutional because it includes the provisions set up by the US Supreme Court in Stenberg v Carhart.
Providers
Providers of elective induced abortions are generally obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers — physicians, physician assistants, midwives, and nurse practitioners — to perform these procedures. Various factors over the years have influenced the number of providers.
Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Thus, few board-certified gynecologists are actually qualified to perform the procedure. Increasing violence against providers and clinics has further decreased providers' willingness to provide abortion services. A "graying" has occurred in providers who continue to perform abortions. Most represent an older population of clinicians who became committed to providing access to safe, legal abortions after caring for young women who experienced morbidity or died from complications of an illegal abortion. For example, the number of abortion providers decreased by 14% from 1992-1996, suggesting a number of clinicians retired and new clinicians were not taking on the abortion services. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.
Current New York City Mayor Michael Bloomberg, a Republican, proposed a policy that will include abortion training for medical residents in all 11 of the city's hospitals. Recently, the number of abortion providers in the United States has declined because of the aging population of providers and the lack of training during residency. Students, of course, are able to opt out of the training if they are morally opposed to abortion. In contrast, the Kentucky Senate also passed a bill that allows pharmacists who oppose abortion to opt out from dispensing medical abortion pills.
Medical abortion protocols have the potential to expand the number of available providers because arranging for backup with a provider who can perform a surgical abortion is necessary, while having a staff willing to assist at a surgical abortion is not necessary. The role of nurse practitioners, with valid prescription privileges, is unclear at the present time, but these providers may also aid in expanding abortion access.
The US Food and Drug Administration (FDA) has recently approved mifepristone (Mifeprex), also known as RU-486, for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the United States.
A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States. An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are also reviewed in this article (see Medical/Legal Pitfalls).
Abortion postoperative care is often provided at sites where the abortion was not performed, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.
Pathophysiology
Surgical termination
The development of accurate over-the-counter pregnancy tests allows for the diagnosis of pregnancy 1-2 weeks after conception. Terminations performed in this very early time frame have been termed menstrual extractions, a historical reference to a time when, prior to the availability of accurate pregnancy tests, providers made the presumptive diagnosis based on clinical history and performed extremely early suction evacuations without histologic tissue confirmation, allowing for maximum confidentiality for both patient and provider.
Abortions performed prior to 9 weeks from the last menstrual period (LMP) (7 wk from conception) are performed either surgically or medically. From 9 weeks until 14 weeks, an abortion is performed by a dilatation and suction curettage procedure. After 14 weeks, surgical abortions are performed by a dilatation and evacuation procedure. After 20 weeks of gestation, abortions can be performed by labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, or intact dilatation and extraction. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.
Medical termination
Medical abortion is a term applied to a medication-induced elective abortion. This can be accomplished with a variety of medications administered either singly or in succession. Medical abortion has a success rate that ranges from 75-95%, with approximately 2-4% of failed abortions requiring surgical abortion and approximately 5-10% of incomplete abortions, depending on the stage of gestation and the medical products used. For a review of multiple studies, see Kahn et al.1 Patients who select a medical abortion express a slightly greater satisfaction with their route of abortion and, in most cases, express a wish to choose this method again should they have another abortion. Research needs to be performed to more clearly establish which protocol is best, which medications are preferable, and how successfully women and adolescents can diagnose a complete versus an incomplete abortion.
Although a critical shortage of providers exists who can provide surgical abortions, in a recent study by Koenig et al, providers who do not perform surgical abortions have indicated a willingness to provide medical abortions.2
Medical abortions can provide some measure of safety in that they eliminate the risk of cervical lacerations and uterine perforations. Some patients require an emergency surgical abortion, and, for safety concerns, patients undergoing medical abortions need access to providers willing to perform an elective termination.
In September of 2000, the FDA approved mifepristone (RU-486) for use in a specific medical regimen that includes misoprostol administration for those who do not abort with mifepristone alone. Methotrexate and misoprostol are drugs approved for other indications that can also be used for medical termination of pregnancy. Additional research will determine exactly which regimen is ideal for medical abortions.
Medical abortions have additional management issues for patients and clinicians. The process involves bleeding, often heavy, which must be differentiated from hemorrhage. Regardless of the amount of tissue passed, the patient must be seen for evaluation of the completeness of the process.
The medical regimens initiate the process with progesterone receptor blockage by mifepristone without activating the receptor. This leads to a progesterone effect withdrawal from the decidua with ensuing necrosis and eventual detachment of the placenta at its implantation site. Following this with a prostaglandin, usually misoprostol, then leads to uterine activity and expulsion of the products of conception. It works best up to day 49 of pregnancy and regimens up to day 63 are effective as well.
A rare and serious infection of Clostridium sordellii is related to medical abortions. Four deaths associated with this infection have been reported since 2001. Fatal infections are rare, occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less fatal than penicillin-induced anaphylaxis (1 in 50,000 uses).
Frequency
United States
Abortion statistics are available from a variety of sources, including, the US Centers for Disease Control and Prevention, The Alan Guttmacher Institute, and the National Abortion Federation. Information and specific instructions regarding state requirements for abortion reporting are available from vital statistics offices in each state health department. Comprehensive statistical information is regarded as important in ensuring the utmost in patient safety.
In 1996, approximately 20 women for every 1000 women aged 15-44 years had an abortion, and for every 1000 live births, approximately 325 abortions were performed. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social milieu of abortion have led to more women seeking terminations later in pregnancy. In 2000, only 12.5% of abortions were performed in the second trimester of pregnancy (CDC), of which almost all between 13 and 20 weeks were surgical abortions, the others being performed by labor induction.
International
Globally, abortion mortality accounts for at least 13% of all maternal mortality. New estimates are that 50 million induced abortions are performed each year in developing countries, with approximately 20 million of these performed unsafely because of conditions or lack of provider training. Maternal mortality is 600,000 deaths per year due to pregnancy-related causes, and 99% of these deaths are in developing countries. While in the United States, only 1% of abortions are performed by induction, globally about 16% of all abortions, some as early as 12 weeks of gestation are performed by labor induction.
Mortality/Morbidity
The safety of abortion is well established, with infection rates less than 1%, and fewer than 1 in 100,000 mortalities occurs from first-trimester abortions. At every gestational age, elective abortion is safer for the mother than carrying a pregnancy to term. Medical abortions, or those performed primarily by medication prior to any surgical intervention, are even safer than surgical abortions at the same gestational age.
Race
Unintended pregnancy rates are 40% among white women, 69% among black women, and 54% among Hispanic women. (Guttmacher Institute, July 2008)
Age
Abortion rates are highest among 20- to 24-year-old women; rates are lowest among women younger than 20 years and those older than 40 years. Although abortion rates are lower in the latter two groups, these women are far more likely to have a pregnancy termination if they become pregnant.
Clinical
History
Most terminations of pregnancy are performed after a brief and targeted gynecologic and obstetric history is obtained. Providers should obtain information about any prior pregnancies and information regarding any treatment or care during the current pregnancy. The history taking should also focus on prior gynecologic disease, with particular attention to previous or current sexually transmitted infections (STIs). Medical history that might be important includes a history of diabetes, hypertension, heart disease, anemia, bleeding disorders, or gynecologic surgery. A history of active medical problems may indicate that the patient needs to be medically stabilized prior to the abortion or have the procedure performed in a facility that can handle special medical problems.
- Maternal indications for abortion
- With advances in perinatal care, few medical contraindications exist for pregnancy. Perinatologists, obstetricians, and abortion counselors prefer to put the risks in the context of the statistical likelihood of complications, and then let the patient make her final decision.
- Women take on less risk, regardless of health or gestational age, to terminate a pregnancy than to continue to term. These abortions have been termed therapeutic abortions.
- Maternal medical conditions that carry significant risks in pregnancy include severe diabetes with retinopathy, cardiac or renal complications, advanced cardiac disease, renal failure, sickle cell disease, autoimmune disease, and psychiatric disease.
- Cardiac conditions that still carry maternal mortality rates of 5-15% include severe mitral stenosis, coarctation of the aorta, uncorrected tetralogy of Fallot, aortic stenosis, history of myocardial infarction, and the presence of artificial heart valves. Higher mortality rates have been reported in women with coarctation of the aorta with vascular involvement, pulmonary hypertension, Marfan syndrome with aortic involvement, and myocardial infarction in pregnancy.
- Nondirective counseling can help a woman select her choice.
- Fetal indications for abortion
- Fetal conditions that are incompatible with life include anencephaly, trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly, and some hydrocephalic cases.
- Many hypoplastic cardiac conditions are also incompatible with life. However, with cardiac transplantation, some infants can now survive with these defects.
- The most common fetal anomalies encountered in abortion counseling include most fetal cardiac anomalies; trisomy 21; open and closed neural tube defects; limb, face, or cleft abnormalities; esophageal or duodenal atresia; chest and abdominal wall defects; cystic kidneys or hydronephrosis; intracranial calcifications suggestive of viral disease; or diaphragmatic defects.
Physical
- A brief physical examination is usually conducted prior to an abortion procedure. The focus is on dating the pregnancy, ensuring the absence of other gynecologic pathology (particularly STIs), and assessing the patient's suitability for an operative procedure under local sedation.
- Note any vaginal or cervical discharge, the nature of the cervix, and any lesions. Document the presence or absence of any ovarian pathology.
- If the patient is planned for general anesthesia, a typical screening preoperative physical examination can be performed.
More on Elective Abortion |
 Overview: Elective Abortion |
| Differential Diagnoses & Workup: Elective Abortion |
| Treatment & Medication: Elective Abortion |
| Follow-up: Elective Abortion |
| References |
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Further Reading
Keywords
abortion, surgical termination of pregnancy, elective termination of pregnancy, medical termination of pregnancy, voluntary abortion, therapeutic abortion, menstrual extraction, fetal reduction, pregnancy termination, partial birth abortion, Roe v Wade, intact dilatation and extraction, late-term abortion, elective induced abortion, surgical abortion, medical abortion, dilatation and suction curettage procedure, dilatation and evacuation procedure, labor induction, prostaglandin labor induction, saline infusion, hysterotomy, dilatation and extraction, medication-induced elective abortion, misoprostol, mifepristone, RU-486, incomplete abortion, complete abortion, therapeutic abortion, prostaglandin-induced second-trimester abortion, saline-induced abortion, dilatation and curettage
