- Author: Frances E Casey, MD, MPH; Chief Editor: Michel E Rivlin, MD more...
Elective termination of pregnancy remains common in the United States and worldwide, and controversy and debate are ongoing. Accurate statistics have been kept since the enactment of the 1973 US Supreme Court decisions legalizing abortions. Note the following:
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 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. Based on estimated lifetime risk, each American woman is expected to have 3.2 pregnancies, of which 2 will be a live birth, 0.7 will be an induced abortion, and 0.5 will be a miscarriage. Using 1996 data, this translates into 3.89 million live births, 1.37 million abortions, and 0.98 million miscarriages.
The pregnancy-associated mortality rate in the United States from 1998-2005 among women who delivered live neonates was 8.8 deaths per 100,000 live births. The mortality rate related to induced abortion was 0.6 deaths per 100,000 abortions. The risk of death associated with childbirth is approximately 14 times higher than that with abortion, and overall morbidity associated with childbirth exceeds that with abortion. 
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.
Statistic reporting in the United States is from the Centers for Disease Control and Prevention (CDC). The Alan Guttmacher Institute (AGI) is a private organization that is not subject to the reporting limitations of state health departments. AGI contacts abortion providers directly and provides abortion data every 4-5 years. A previous report documented a discrepancy of approximately 12% between statistical figures presented by the CDC compared with those of AGI (the latter generally having higher estimates).
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.
Among practicing obstetricians and gynecologists in the United States, 97% encountered patients seeking abortions, whereas only 14% performed them.  Access to abortion was particularly limited in rural communities and in the South and Midwest.
Legalization of abortion
Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time.
The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars' interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. The ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic Church declared abortion a sin punishable by excommunication.
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.
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.
The abortion debate
Advances in neonatal medicine leading to improved fetal survival very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on the beginning of life.
Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments has kept the debate both vocal and contentious. These potential therapies may be indicated in the treatment of diabetes, Parkinson disease, kidney disease, and cartilage diseases, among others.
Current national regulations prohibit most fetal tissue research, but the National Institute of Health revealed late in the year 2000 that it would allow stem cell research. In June 2002, however, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface. The American Congress of Obstetrics and Gynecology specifically has a policy against the use of sex determination for the expressed purpose of selectively terminating female children.
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. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women's health was the motivating force. 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. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3%. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother's life.
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. During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if (1) pregnancy would "gravely impair the physical and mental health of the mother," (2) the child born was likely to have "grave physical and mental defects," or (3) the pregnancy was the result of rape or incest.
Prior to the 1960s, an estimated 9 of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and lay settings, and almost 20% of all pregnancy-related complications were due to illegal abortions (Kinsey). 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 in 1965, which 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.
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 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.
By 1999, 38 states had such laws, and 29 states enforce their laws. Currently, only Connecticut, Maine, and the District of Columbia have laws that affirm the rights of a minor to seek her own abortion. For a summary of laws, see Minors' Right to Consent to Health Care and to Make Other Important Decisions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
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.
Mandatory waiting periods
Mandatory waiting periods mandate by law that the woman seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives anywhere from 24 to 72 hours prior to her procedure.
These laws have the effect of increasing the percentage of second-trimester abortions in states with these laws. Given that women must travel long distances to access services, these laws quickly become restrictive for low-income care recipients.
State-developed counseling materials
A variety of state-developed counseling materials have come into use across the United States. These counseling materials may include falsified information such as suggesting an increased risk of breast cancer for women who have had an abortion, although a 2003 National Cancer Institute census report found no such link. Other states have developed unfounded and unreferenced materials on topics such as fetal pain, the psychological effects of abortion, and coercion.
Although only 2% of the population verbalizes opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
By 1998, 28 states had passed bans on this procedure, referred to in the lay press as a partial-birth abortion, which is the medical procedure intact dilatation and extraction. The descriptive language in the US Criminal Code defines "partial-birth abortion" as "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.
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.
Eroding abortion rights
Although the fundamental right to have an abortion has remained intact by basic statute, poor women have had their rights eroded by the Hyde amendment in 1976 that prohibited the use of federal funds for abortions except in the case of maternal life endangerment. This, in conjunction with a rise in the takeover of hospitals in some regions by religious organizations opposed to abortion and contraception, has restricted access to abortion. Almost one third of publicly funded recipients are prevented from having a termination by lack of access to care. Public controversy has raged on the specific question of whether individuals or institutions should be allowed to refuse medical care. Although 45 states have enacted laws allowing such refusal, only 5 have also enacted laws that require the provider to notify patients of their refusal. These provisions extend to contraceptive and sterilization services.
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. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.
New York City's former mayor, Michael Bloomberg, proposed a policy that would include abortion training for medical residents in all 11 of the city's hospitals. It has been shown that the availability and type of abortion training is independently associated with abortion procedural experience. 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.[5, 6] Students, of course, are able to opt out of the training if they are morally opposed to abortion.
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.
Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (eg, family practitioners, nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Epidemiologic research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
Keeping abortions safe, legal, and rare are the goals of abortion providers. For information from physicians regarding these goals, see Physicians for Reproductive Choice and Health.
As providers have decreased in number, women are traveling farther to obtain abortions, presenting later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
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.
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.
The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.
Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.
The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in the past 20 years. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.
Indications for pregnancy termination
There are medical factors both maternal and fetal that contribute to the decision. These factors have been termed therapeutic abortion, defined as the termination of pregnancy for medical indications, including the following:
Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother is a factor. The maternal medical condition and a reasonable prediction of future circumstances as well as the consequences of the pregnancy as it progresses must be considered.
The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:
Cervical cancer (1 case per 2200 pregnancies)
Breast cancer (1 case per 3000 pregnancies)
Melanoma (0.14-2.8 cases per 1000 pregnancies)
Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)
Rape or incest and fetal anomalies when pregnancy outcome is likely to be birth of a child with significant mental or physical defects or high likelihood of intrauterine or neonatal death are also considered.
Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald, the suggested causes of fetal anomalies are as follows:
Genetic (ie, chromosomal) (20-25%)
Fetal infections (3-5%)
Maternal disease (4%)
Drugs/medications (< 1%)
The data that indicate increased maternal risk from fetal demise primarily date from the preultrasonography era, when prolonged retained products of conception put the patient at risk of coagulopathies. Current management thus centers on prompt diagnosis and uterine evacuation, particularly in the second trimester.
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. Most abortions are performed in an ambulatory office setting under local anesthesia with or without sedation.
The following methods are available for surgical abortion:
Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks' gestation and is 99.2% effective.
Suction curettage is used at 6-14 weeks' gestation.
Sharp curettage alone is not recommended due to risk of increased blood loss, adhesive disease and retained product of conception (POC) compared with suction.
Dilation and extraction (D&E) is used at 14-24 weeks' gestation.
Intact dilation and extraction (D&X) is used at more than 18 weeks' gestation, but is not performed in the US without prior feticide treatments due to current laws.
Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated.
Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus.
Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 89% occur in the first 12 weeks., As of 2011, medication abortion accounted for 23% of all abortions, an increase from 6% in 2001.
In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. Hysterectomy/hysterotomy procedures have the highest risk of complications but may still have a role in very rare clinical situations (eg, stenotic cervical os, placenta accreta). D&E is considered the safest form of abortion in the second trimester. Little published data exist regarding the frequency or complication rates for D&X. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians.
Labor induction methods have an increased risk of complications such as retained placenta as compared with that of D&E. The Society of Family Planning released second trimester induction guidelines in February of 2011.
Women with a history of prior cesarean delivery are at increased risk of morbidity/mortality when undergoing labor induction as a form of surgical abortion. Labor induction has been associated with an increased odds ratio of uterine rupture and risk of blood transfusion in women with a history of prior cesarean delivery as compared with those without a uterine scar. Women with a history of a prior cesarean delivery may safely be offered D&E by a trained provider without increased risk.
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 with the combination of mifepristone and vaginal or buccal misoprostol has a success rate of 93-95% to 63 days gestation., Ongoing pregnancy is rare, occurring in <0.4%. It is more common, occurring in 3-5% of patients, to have retained products and these patients often require a suction procedure due to ongoing symptoms. Research continues to be performed to more clearly establish which protocol is best, which medications are preferable, and best methods to 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.
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.
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 standard has been that the patient must be seen for evaluation of the completeness of the process. Many providers have also routinely used ultrasonography to assess abortion outcome. However, a recent study showed that using a low-sensitivity pregnancy test and clinical examination is sufficient for completeness assessment.
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). Few direct comparisons of surgical and medical abortions are available, but using the data from the distributor of the mifepristone, 11 pregnancy-related deaths occurred in 1.8 million medical terminations from approximately 2000-2011, with a mortality rate of 0.7/100,000, which is virtually identical to the rate of mortality from surgical abortions.
Abortion statistics are available from a variety of sources, including, the US Centers for Disease Control and Prevention (CDC), 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.
Each year, 1.7% of U.S. women aged 15-44 have an abortion. Half have had at least one prior abortion. 89% of abortions occur less than 12 weeks gestation.
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. Up to 44,000 abortion related deaths occurred in 2014. 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.
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.
Mortality rates are highest with the most invasive procedures and with increasing gestational age, as follows: 0.4 of 100,000 cases at less than 8 weeks of gestation, 3 of 100,000 cases at 13-15 weeks of gestation, and 12 of 100,000 cases at more than 21 weeks of gestation. Causes of death include infection, hemorrhage, pulmonary embolism, anesthesia complications, and amniotic fluid embolism. Death rates with hysterotomy/hysterectomy are 64.9 of 100,000 cases at 13-15 weeks of gestation and 123 of 100,000 cases at more than 21 weeks of gestation.
Unintended pregnancy rates are 36% among non-Hispanic white women, 30% among non-Hispanic black women, and 25% among Hispanic women.
Women in their 20s account for more than half of all abortions. Eighteen percent of U.S. Women obtaining abortion are teenagers. Although abortion rates are lower for women less than 20 and over 40, these women are far more likely to have a pregnancy termination if they become pregnant.
Mikolajczak M, Bilewicz M. Foetus or child? Abortion discourse and attributions of humanness. Br J Soc Psychol. 2014 Nov 24. [Medline].
Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012 Feb. 119(2 Pt 1):215-9. [Medline].
Stulberg DB, Dude AM, Dahlquist I, Curlin FA. Abortion provision among practicing obstetrician-gynecologists. Obstet Gynecol. 2011 Sep. 118(3):609-14. [Medline].
Bridges KM. When pregnancy is an injury: rape, law, and culture. Stanford Law Rev. 2013 Mar. 65(3):457-516. [Medline].
Turk JK, Preskill F, Landy U, Rocca CH, Steinauer JE. Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey. Contraception. 2014 Apr. 89(4):271-7. [Medline].
Shanahan MA, Metheny WP, Star J, Peipert JF. Induced abortion. Physician training and practice patterns. J Reprod Med. 1999 May. 44(5):428-32. [Medline].
Joffe C. The politicization of abortion and the evolution of abortion counseling. Am J Public Health. 2013 Jan. 103(1):57-65. [Medline].
Cunningham GF, MacDonald PC, Gant NF. Abortion. Williams Obstetrics. 19th ed. 1993. 661-90.
Induced Abortion in the United States. Guttmacher Institute. Available at http://www.guttmacher.org/pubs/fb_induced_abortion.html. July 2014; Accessed: February 29, 2015.
Chasen ST, Kalish RB, Gupta M, Kaufman JE, Rashbaum WK, Chervenak FA. Dilation and evacuation at >or=20 weeks: comparison of operative techniques. Am J Obstet Gynecol. 2004 May. 190(5):1180-3. [Medline].
Bryant AG, Grimes DA, Garrett JM, Stuart GS. Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation. Obstet Gynecol. 2011 Apr. 117(4):788-92. [Medline].
Borgatta L, Kapp N. Clinical guidelines. Labor induction abortion in the second trimester. Contraception. 2011 Jul. 84(1):4-18. [Medline].
Kahn JG, Becker BJ, MacIsaa L, et al. The efficacy of medical abortion: a meta-analysis. Contraception. 2000 Jan. 61(1):29-40. [Medline].
Koenig JD, Tapias MP, Hoff T, Stewart FH. Are US health professionals likely to prescribe mifepristone or methotrexate?. J Am Med Womens Assoc. 2000. 55(3 Suppl):155-60. [Medline].
Clark W, Bracken H, Tanenhaus J, Schweikert S, Lichtenberg ES, Winikoff B. Alternatives to a routine follow-up visit for early medical abortion. Obstet Gynecol. 2010 Feb. 115(2 Pt 1):264-72. [Medline].
Jones RK, Finer LB, Singh S. Characteristics of U.S. Abortion Patients, 2008. New York: Guttmacher Institute; 2010.
Hayes JL, Achilles SL, Creinin MD, Reeves MF. Outcomes of medical abortion through 63 days in women with twin gestations. Contraception. 2011 Nov. 84(5):505-7. [Medline].
Kornfield SL, Geller PA. Mental health outcomes of abortion and its alternatives: implications for future policy. Womens Health Issues. 2010 Mar-Apr. 20(2):92-5. [Medline].
Ngoc NT, Shochet T, Raghavan S, et al. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: a randomized controlled trial. Obstet Gynecol. 2011 Sep. 118(3):601-8. [Medline].
Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstet Gynecol. 2011 Aug. 118(2 Pt 1):296-303. [Medline].
Mifeprex (misoprostol) [package insert]. New York, NY: Danco Laboratories, LCC. March 2016. Available at [Full Text].
Dickinson JE, Doherty DA. Optimization of third-stage management after second-trimester medical pregnancy termination. Am J Obstet Gynecol. 2009 Sep. 201(3):303.e1-7. [Medline].
Wildschut H, Both MI, Medema S, Thomee E, Wildhagen MF, Kapp N. Medical methods for mid-trimester termination of pregnancy. Cochrane Database Syst Rev. 2011 Jan 19. 1:CD005216. [Medline].
Challis D, Gratacos E, Deprest JA. Cord occlusion techniques for selective termination in monochorionic twins. J Perinat Med. 1999. 27(5):327-38. [Medline].
Edlow AG, Hou MY, Maurer R, Benson C, Delli-Bovi L, Goldberg AB. Uterine evacuation for second-trimester fetal death and maternal morbidity. Obstet Gynecol. 2011 Feb. 117(2 Pt 1):307-16. [Medline].
Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception. 2011 Jan. 83(1):41-7. [Medline].
Pridmore BR, Chambers DG. Uterine perforation during surgical abortion: a review of diagnosis, management and prevention. Aust N Z J Obstet Gynaecol. 1999 Aug. 39(3):349-53. [Medline].
Hakim-Elahi E, Tovell HM, Burnhill MS. Complications of first-trimester abortion: a report of 170,000 cases. Obstet Gynecol. 1990 Jul. 76(1):129-35. [Medline].
Kafrissen ME, Barke MW, Workman P, Schulz KF, Grimes DA. Coagulopathy and induced abortion methods: rates and relative risks. Am J Obstet Gynecol. 1983 Oct 1. 147(3):344-5. [Medline].
Perry KG Jr, Rinehart BK, Terrone DA, Martin RW, May WL, Roberts WE. Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol. Am J Obstet Gynecol. 1999 Nov. 181(5 Pt 1):1057-61. [Medline].
Kuppermann M, Nakagawa S, Cohen SR, et al. Attitudes toward prenatal testing and pregnancy termination among a diverse population of parents of children with intellectual disabilities. Prenat Diagn. 2011 Dec. 31(13):1251-8. [Medline].
Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol. 2006 Jan. 194(1):92-4. [Medline].
Zhou W, Sorensen HT, Olsen J. Induced abortion and subsequent pregnancy duration. Obstet Gynecol. 1999 Dec. 94(6):948-53. [Medline].
Hendricks MS, Chow YH, Bhagavath B, Singh K. Previous cesarean section and abortion as risk factors for developing placenta previa. J Obstet Gynaecol Res. 1999 Apr. 25(2):137-42. [Medline].
Eras JL, Saftlas AF, Triche E, Hsu CD, Risch HA, Bracken MB. Abortion and its effect on risk of preeclampsia and transient hypertension. Epidemiology. 2000 Jan. 11(1):36-43. [Medline].
Acharya PS, Gluckman SJ. Bacteremia following placement of intracervical laminaria tents. Clin Infect Dis. 1999 Sep. 29(3):695-7. [Medline].
ACOG. ACOG practice bulletin. Clinical management guidelines of obstetrician-gynecologists. Number 67, October 2005. Medical management of abortion. Obstet Gynecol. 2005 Oct. 106(4):871-82. [Medline].
ACOG. American College of Obstetricians and Gynecologists. Methods of Midtrimester Abortion. ACOG Technical Bulletin. 1987. 109:602-05.
ACOG Compendium of Selected Publications. American College of Obstetricians and Gynecologists. Abortion Policy. 2005. 865-867.
Aiyer AN, Ruiz G, Steinman A, Ho GY. Influence of physician attitudes on willingness to perform abortion. Obstet Gynecol. 1999 Apr. 93(4):576-80. [Medline].
Ashok PW, Templeton A. Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol. 1999 Jul. 106(7):706-10. [Medline].
Baird DT. Mode of action of medical methods of abortion. J Am Med Womens Assoc. 2000. 55(3 Suppl):121-6. [Medline].
Ballagh SA, Harris HA, Demasio K. Is curettage needed for uncomplicated incomplete spontaneous abortion?. Am J Obstet Gynecol. 1998 Nov. 179(5):1279-82. [Medline].
Bartholomew LL, Grimes DA. The alleged association between induced abortion and risk of breast cancer: biology or bias?. Obstet Gynecol Surv. 1998 Nov. 53(11):708-14. [Medline].
Begley AM. Preparation for practice in the new millennium: a discussion of the moral implications of multifetal pregnancy reduction. Nurs Ethics. 2000 Mar. 7(2):99-112. [Medline].
Berer M. Making abortions safe: a matter of good public health policy and practice. Bull World Health Organ. 2000. 78(5):580-92. [Medline].
Bernick BA, Ufberg DD, Nemiroff R, Donnenfeld A, Tolosa JE. Success rate of cytogenetic analysis at the time of second-trimester dilation and evacuation. Am J Obstet Gynecol. 1998 Oct. 179(4):957-61. [Medline].
Bernstein PS, Rosenfield A. Abortion and maternal health. Int J Gynaecol Obstet. 1998 Dec. 63 Suppl 1:S115-22. [Medline].
Blanchard K, Winikoff B, Ellertson C. Misoprostol used alone for the termination of early pregnancy. A review of the evidence. Contraception. 1999 Apr. 59(4):209-17. [Medline].
Borgatta L, Burnhill M, Haskell S, Nichols M, Leonhardt K. Instituting medical abortion services: changes in outcome and acceptability related to provider experience. J Am Med Womens Assoc. 2000. 55(3 Suppl):173-6. [Medline].
Borgatta L, Chen AY, Reid SK, Stubblefield PG, Christensen DD, Rashbaum WK. Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion. Am J Obstet Gynecol. 2001 Sep. 185(3):530-6. [Medline].
Borgmann CE, Jones BS. Legal issues in the provision of medical abortion. Am J Obstet Gynecol. 2000 Aug. 183(2 Suppl):S84-94. [Medline].
Bourguignon A, Briscoe B, Nemzer L. Genetic abortion: considerations for patient care. J Perinat Neonatal Nurs. 1999 Sep. 13(2):47-58. [Medline].
Breitbart V, Repass DC. The counseling component of medical abortion. J Am Med Womens Assoc. 2000. 55(3 Suppl):164-6. [Medline].
Cakir L, Dilbaz B, Caliskan E, Dede FS, Dilbaz S, Haberal A. Comparison of oral and vaginal misoprostol for cervical ripening before manual vacuum aspiration of first trimester pregnancy under local anesthesia: a randomized placebo-controlled study. Contraception. 2005 May. 71(5):337-42. [Medline].
Castadot RG. Pregnancy termination: techniques, risks, and complications and their management. Fertil Steril. 1986 Jan. 45(1):5-17. [Medline].
Cates W, Ellertson C. Contraceptive Technology. Hatcher RA, Trussel J, Stewart F, et al. Abortion. 17th ed. New York, NY: Ardent Media; 1998. 682-697.
Chapman SJ, Crispens M, Owen J, Savage K. Complications of midtrimester pregnancy termination: the effect of prior cesarean delivery. Am J Obstet Gynecol. 1996 Oct. 175(4 Pt 1):889-92. [Medline].
Christin-Maitre S, Bouchard P, Spitz IM. Medical termination of pregnancy. N Engl J Med. 2000 Mar 30. 342(13):946-56. [Medline].
Chung TK, Lee DT, Cheung LP, Haines CJ, Chang AM. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril. 1999 Jun. 71(6):1054-9. [Medline].
Clark S, Ellertson C, Winikoff B. Is medical abortion acceptable to all American women: the impact of sociodemographic characteristics on the acceptability of mifepristone-misoprostol abortion. J Am Med Womens Assoc. 2000. 55(3 Suppl):177-82. [Medline].
Cohen AL, Bhatnagar J, Reagan S, et al. Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion. Obstet Gynecol. 2007 Nov. 110(5):1027-33. [Medline].
Cole DS, Bruck LR. Anaphylaxis after laminaria insertion. Obstet Gynecol. 2000 Jun. 95(6 Pt 2):1025. [Medline].
Collins MK, Moreau JF, Opel D, et al. Compliance with pregnancy prevention measures during isotretinoin therapy. J Am Acad Dermatol. 2014 Jan. 70(1):55-9. [Medline].
Cook RJ, Dickens BM. Human rights and abortion laws. Int J Gynaecol Obstet. 1999 Apr. 65(1):81-7. [Medline].
Coyaji K. Early medical abortion in India: three studies and their implications for abortion services. J Am Med Womens Assoc. 2000. 55(3 Suppl):191-4. [Medline].
Creinin MD. Conception rates after abortion with methotrexate and misoprostol. Int J Gynaecol Obstet. 1999 May. 65(2):183-8. [Medline].
Creinin MD. Medical abortion regimens: historical context and overview. Am J Obstet Gynecol. 2000 Aug. 183(2 Suppl):S3-9. [Medline].
Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol. 2004 May. 103(5 Pt 1):851-9. [Medline].
Creinin MD, Jerald H. Success rates and estimation of gestational age for medical abortion vary with transvaginal ultrasonographic criteria. Am J Obstet Gynecol. 1999 Jan. 180(1 Pt 1):35-41. [Medline].
Creinin MD, Pymar HC. Medical abortion alternatives to mifepristone. J Am Med Womens Assoc. 2000. 55(3 Suppl):127-32, 150. [Medline].
Creinin MD, Spitz IM. Use of various ultrasonographic criteria to evaluate the efficacy of mifepristone and misoprostol for medical abortion. Am J Obstet Gynecol. 1999 Dec. 181(6):1419-24. [Medline].
Creinin MD, Wiebe E, Gold M. Methotrexate and misoprostol for early abortion in adolescent women. J Pediatr Adolesc Gynecol. 1999 May. 12(2):71-7. [Medline].
Daling JR, Emanuel I. Induced abortion and subsequent outcome of pregnancy. A matched cohort study. Lancet. 1975 Jul 26. 2(7926):170-3. [Medline].
Davis A, Westhoff C, De Nonno L. Bleeding patterns after early abortion with mifepristone and misoprostol or manual vacuum aspiration. J Am Med Womens Assoc. 2000. 55(3 Suppl):141-4. [Medline].
Dean G, Cardenas L, Darney P, Goldberg A. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. Contraception. 2003 Mar. 67(3):201-6. [Medline].
Delfs E, Katayama KP. Surgical Management of Reproductive Failure and Abortion. Te Linde's Operative Gynecology. Fifth Edition. 1977. 429-451.
Dobie SA, Hart LG, Glusker A, Madigan D, Larson EH, Rosenblatt RA. Abortion services in rural Washington State, 1983-1984 to 1993-1994: availability and outcomes. Fam Plann Perspect. 1999 Sep-Oct. 31(5):241-5. [Medline].
Drey EA, Thomas LJ, Benowitz NL, Goldschlager N, Darney PD. Safety of intra-amniotic digoxin administration before late second-trimester abortion by dilation and evacuation. Am J Obstet Gynecol. 2000 May. 182(5):1063-6. [Medline].
Edmondson AS, Cooke EM. The development and assessment of a bacteriocin typing method for Klebsiella. J Hyg (Lond). 1979 Apr. 82(2):207-23. [Medline].
Elimian A, Verma U, Tejani N. Effect of causing fetal cardiac asystole on second-trimester abortion. Obstet Gynecol. 1999 Jul. 94(1):139-41. [Medline].
Elul B, Ellertson C, Winikoff B, Coyaji K. Side effects of mifepristone-misoprostol abortion versus surgical abortion. Data from a trial in China, Cuba, and India. Contraception. 1999 Feb. 59(2):107-14. [Medline].
Elul B, Pearlman E, Sorhaindo A, Simonds W, Westhoff C. In-depth interviews with medical abortion clients: thoughts on the method and home administration of misoprostol. J Am Med Womens Assoc. 2000. 55(3 Suppl):169-72. [Medline].
Epner JE, Jonas HS, Seckinger DL. Late-term abortion. JAMA. 1998 Aug 26. 280(8):724-9. [Medline].
Evans MI, Goldberg JD, Horenstein J, et al. Selective termination for structural, chromosomal, and mendelian anomalies: international experience. Am J Obstet Gynecol. 1999 Oct. 181(4):893-7. [Medline].
Fitzpatrick KM, Wilson M. Exposure to violence and posttraumatic stress symptomatology among abortion clinic workers. J Trauma Stress. 1999 Apr. 12(2):227-42. [Medline].
Fong YF, Singh K, Prasad RN. Severe hyperthermia following use of vaginal misoprostol for pre-operative cervical priming. Int J Gynaecol Obstet. 1999 Jan. 64(1):73-4. [Medline].
Frank PI, McNamee R, Hannaford PC, Kay CR, Hirsch S. The effect of induced abortion on subsequent pregnancy outcome. Br J Obstet Gynaecol. 1991 Oct. 98(10):1015-24. [Medline].
Gerhardt A, Zotz RB, Stockschlaeder M, Scharf RE. Fondaparinux is an effective alternative anticoagulant in pregnant women with high risk of venous thromboembolism and intolerance to low-molecular-weight heparins and heparinoids. Thromb Haemost. 2007 Mar. 97(3):496-7. [Medline].
Geva E, Fait G, Yovel I, et al. Second-trimester multifetal pregnancy reduction facilitates prenatal diagnosis before the procedure. Fertil Steril. 2000 Mar. 73(3):505-8. [Medline].
Gouk EV, Lincoln K, Khair A, Haslock J, Knight J, Cruickshank DJ. Medical termination of pregnancy at 63 to 83 days gestation. Br J Obstet Gynaecol. 1999 Jun. 106(6):535-9. [Medline].
Grimes D, Schulz K, Stanwood N. Immediate post-abortal insertion of intrauterine devices. Cochrane Database Syst Rev. 2000. CD001777. [Medline].
Grimes DA. A 26-year-old woman seeking an abortion. JAMA. 1999 Sep 22-29. 282(12):1169-75. [Medline].
Grimes DA. The continuing need for late abortions. JAMA. 1998 Aug 26. 280(8):747-50. [Medline].
Grimes DA. Unsafe abortion: the silent scourge. Br Med Bull. 2003. 67:99-113. [Medline].
Grimes DA, Schulz KF. Morbidity and mortality from second-trimester abortions. J Reprod Med. 1985 Jul. 30(7):505-14. [Medline].
Hamoda H, Ashok PW, Flett GM, Templeton A. A randomised controlled trial of mifepristone in combination with misoprostol administered sublingually or vaginally for medical abortion up to 13 weeks of gestation. BJOG. 2005 Aug. 112(8):1102-8. [Medline].
Hamoda H, Ashok PW, Flett GM, Templeton A. Medical abortion at 64 to 91 days of gestation: a review of 483 consecutive cases. Am J Obstet Gynecol. 2003 May. 188(5):1315-9. [Medline].
Hamoda H, Ashok PW, Flett GM, Templeton A. Medical abortion at 9-13 weeks' gestation: a review of 1076 consecutive cases. Contraception. 2005 May. 71(5):327-32. [Medline].
Hassouna A, Allam H. Limited dose warfarin throughout pregnancy in patients with mechanical heart valve prosthesis: a meta-analysis. Interact Cardiovasc Thorac Surg. 2014 Jun. 18(6):797-806. [Medline].
Heath V, Chadwick V, Cooke I, Manek S, MacKenzie IZ. Should tissue from pregnancy termination and uterine evacuation routinely be examined histologically?. BJOG. 2000 Jun. 107(6):727-30. [Medline].
Hellberg D, Mogilevkina I, Mardh PA. Sexually transmitted diseases and gynecologic symptoms and signs in women with a history of induced abortion. Sex Transm Dis. 1999 Apr. 26(4):197-200. [Medline].
Henshaw SK. Abortion incidence and services in the United States, 1995-1996. Fam Plann Perspect. 1998 Nov-Dec. 30(6):263-70, 287. [Medline].
Hern WM. Second-trimester surgical abortions. Sciarra JJ. Gynecology and Obstetrics. Philadelphia, PA: JB Lippincott Co; 2002.
Isley MM, Blumenthal P. Medical Abortion What's Old, what's new?. Contemporary OB GYN. 2008 Apr 15. 30-38.
Jackson RA, Teplin VL, Drey EA, Thomas LJ, Darney PD. Digoxin to facilitate late second-trimester abortion: a randomized, masked, placebo-controlled trial. Obstet Gynecol. 2001 Mar. 97(3):471-6. [Medline].
Jain JK, Kuo J, Mishell DR Jr. A comparison of two dosing regimens of intravaginal misoprostol for second-trimester pregnancy termination. Obstet Gynecol. 1999 Apr. 93(4):571-5. [Medline].
Jain JK, Meckstroth KR, Mishell DR Jr. Early pregnancy termination with intravaginally administered sodium chloride solution-moistened misoprostol tablets: historical comparison with mifepristone and oral misoprostol. Am J Obstet Gynecol. 1999 Dec. 181(6):1386-91. [Medline].
Jain JK, Meckstroth KR, Park M, Mishell DR Jr. A comparison of tamoxifen and misoprostol to misoprostol alone for early pregnancy termination. Contraception. 1999 Dec. 60(6):353-6. [Medline].
Jensen JT, Harvey SM, Beckman LJ. Acceptability of suction curettage and mifepristone abortion in the United States: a prospective comparison study. Am J Obstet Gynecol. 2000 Jun. 182(6):1292-9. [Medline].
Jensen MP, Miller L, Fisher LD. Assessment of pain during medical procedures: a comparison of three scales. Clin J Pain. 1998 Dec. 14(4):343-9. [Medline].
Jermy K, Oyelese O, Bourne T. Uterine anomalies and failed surgical termination of pregnancy: the role of routine preoperative transvaginal sonography. Ultrasound Obstet Gynecol. 1999 Dec. 14(6):431-3. [Medline].
Jones BS, Heller S. Providing medical abortion: legal issues of relevance to providers. J Am Med Womens Assoc. 2000. 55(3 Suppl):145-50. [Medline].
Joyce T, Kaestner R. The impact of Mississippi's mandatory delay law on the timing of abortion. Fam Plann Perspect. 2000 Jan-Feb. 32(1):4-13. [Medline].
Kafrissen ME, Grimes DA, Hogue CJ, Sacks JJ. Cluster of abortion deaths at a single facility. Obstet Gynecol. 1986 Sep. 68(3):387-9. [Medline].
Kalish RB, Chasen ST, Rosenzweig LB, Rashbaum WK, Chervenak FA. Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome. Am J Obstet Gynecol. 2002 Oct. 187(4):882-5. [Medline].
Keder LM. Best practices in surgical abortion. Am J Obstet Gynecol. 2003 Aug. 189(2):418-22. [Medline].
Kero A, Hogberg U, Lalos A. Wellbeing and mental growth-long-term effects of legal abortion. Soc Sci Med. 2004 Jun. 58(12):2559-69. [Medline].
Kero A. Wellbeing and mental growth - long term effects of legal abortion.
Kjems E, Krag C. Melanoma and pregnancy. A review. Acta Oncol. 1993. 32(4):371-8. [Medline].
Koonin LM. Abortion reporting in the era of medical procedures: why is it important?. J Am Med Womens Assoc. 2000. 55(3 Suppl):203-4. [Medline].
Kruse B. Advanced practice clinicians and medical abortion: increasing access to care. J Am Med Womens Assoc. 2000. 55(3 Suppl):167-8. [Medline].
Kruse B, Poppema S, Creinin MD, Paul M. Management of side effects and complications in medical abortion. Am J Obstet Gynecol. 2000 Aug. 183(2 Suppl):S65-75. [Medline].
Lagan BM, Dolk H, White B, Uges DR, Sinclair M. Assessing the availability of the teratogenic drug isotretinoin outside the pregnancy prevention programme: a survey of e-pharmacies. Pharmacoepidemiol Drug Saf. 2014 Apr. 23(4):411-8. [Medline]. [Full Text].
Lahteenmaki P, Luukkainen T. Return of ovarian function after abortion. Clin Endocrinol (Oxf). 1978 Feb. 8(2):123-32. [Medline].
Larsson PG, Platz-Christensen JJ, Dalaker K, et al. Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study. Acta Obstet Gynecol Scand. 2000 May. 79(5):390-6. [Medline].
Lazovich D, Thompson JA, Mink PJ, Sellers TA, Anderson KE. Induced abortion and breast cancer risk. Epidemiology. 2000 Jan. 11(1):76-80. [Medline].
Levgur M, Abadi MA, Tucker A. Adenomyosis: symptoms, histology, and pregnancy terminations. Obstet Gynecol. 2000 May. 95(5):688-91. [Medline].
Lichtenberg ES, Shott S. A randomized clinical trial of prophylaxis for vacuum abortion: 3 versus 7 days of doxycycline. Obstet Gynecol. 2003 Apr. 101(4):726-31. [Medline].
Linn S, Schoenbaum SC, Monson RR, Rosner B, Stubblefield PG, Ryan KJ. The relationship between induced abortion and outcome of subsequent pregnancies. Am J Obstet Gynecol. 1983 May 15. 146(2):136-40. [Medline].
Lokeland M, Iversen OE, Dahle GS, Nappen MH, Ertzeid L, Bjorge L. Medical abortion at 63 to 90 days of gestation. Obstet Gynecol. 2010 May. 115(5):962-8. [Medline].
Macisaac L, Darney P. Early surgical abortion: an alternative to and backup for medical abortion. Am J Obstet Gynecol. 2000 Aug. 183(2 Suppl):S76-83. [Medline].
MacIsaac L, Grossman D, Balistreri E, Darney P. A randomized controlled trial of laminaria, oral misoprostol, and vaginal misoprostol before abortion. Obstet Gynecol. 1999 May. 93(5 Pt 1):766-70. [Medline].
Major B, Gramzow RH. Abortion as stigma: cognitive and emotional implications of concealment. J Pers Soc Psychol. 1999 Oct. 77(4):735-45. [Medline].
Mansfield C, Hopfer S, Marteau TM. Termination rates after prenatal diagnosis of Down syndrome, spina bifida, anencephaly, and Turner and Klinefelter syndromes: a systematic literature review. European Concerted Action: DADA (Decision-making After the Diagnosis of a fetal Abnormality). Prenat Diagn. 1999 Sep. 19(9):808-12. [Medline].
Martin CW, Brown AH, Baird DT. A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary. Contraception. 1998 Aug. 58(2):99-103. [Medline].
Mayr NA, Wen BC, Saw CB. Radiation therapy during pregnancy. Obstet Gynecol Clin North Am. 1998 Jun. 25(2):301-21. [Medline].
Mcfarlane DR. Induced abortion: an historical overview. Am J Gynecol Health. 1993 May-Jun. 7(3):77-82. [Medline].
Medich DS, Fazio VW. Hemorrhoids, anal fissure, and carcinoma of the colon, rectum, and anus during pregnancy. Surg Clin North Am. 1995 Feb. 75(1):77-88. [Medline].
Miller VL, Ransom SB, Shalhoub A, Sokol RJ, Evans MI. Multifetal pregnancy reduction: perinatal and fiscal outcomes. Am J Obstet Gynecol. 2000 Jun. 182(6):1575-80. [Medline].
Nielsen S, Hahlin M, Platz-Christensen J. Randomised trial comparing expectant with medical management for first trimester miscarriages. Br J Obstet Gynaecol. 1999 Aug. 106(8):804-7. [Medline].
Oteri O, Hopkins R. Second trimester therapeutic abortion using mifepristone and oral misoprostol in a woman with two previous caesarean sections and a cone biopsy. J Matern Fetal Med. 1999 Nov-Dec. 8(6):300-1. [Medline].
Owen J, Hauth JC. Vaginal misoprostol vs. concentrated oxytocin plus low-dose prostaglandin E2 for second trimester pregnancy termination. J Matern Fetal Med. 1999 Mar-Apr. 8(2):48-50. [Medline].
Pakarinen P, Toivonen J, Luukkainen T. Randomized comparison of levonorgestrel- and copper-releasing intrauterine systems immediately after abortion, with 5 years' follow-up. Contraception. 2003 Jul. 68(1):31-4. [Medline].
Papiernik E, Grange G, Zeitlin J. Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order multiple pregnancies?. J Perinat Med. 1998. 26(5):365-70. [Medline].
Paul M. Office management of early induced abortion. Clin Obstet Gynecol. 1999 Jun. 42(2):290-305. [Medline].
Paul M, Lichtenberg ES, Borgatta L. A Clinician's Guide to Medical and Surgical Abortion. New York, NY: Churchill Livingstone; 1999.
Paul M, Schaff E, Nichols M. The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice. Am J Obstet Gynecol. 2000 Aug. 183(2 Suppl):S34-43. [Medline].
Paul ME, Mitchell CM, Rogers AJ, Fox MC, Lackie EG. Early surgical abortion: efficacy and safety. Am J Obstet Gynecol. 2002 Aug. 187(2):407-11. [Medline].
Penfield AJ. Gynecologic Surgery Under Local Anesthesia. Baltimore, Md: Urban & Schwarzenburg; 1986. 65-94.
Perry KG Jr, Rinehart BK, Terrone DA, Martin RW, May WL, Roberts WE. Second-trimester uterine evacuation: A comparison of intra-amniotic (15S)-15-methyl-prostaglandin F2alpha and intravaginal misoprostol. Am J Obstet Gynecol. 1999 Nov. 181(5 Pt 1):1057-61. [Medline].
Pope LM, Adler NE, Tschann JM. Postabortion psychological adjustment: are minors at increased risk?. J Adolesc Health. 2001 Jul. 29(1):2-11. [Medline].
Reeves MF, Lohr PA, Harwood BJ, Creinin MD. Ultrasonographic endometrial thickness after medical and surgical management of early pregnancy failure. Obstet Gynecol. 2008 Jan. 111(1):106-12. [Medline].
Rosenblatt RA, Robinson KB, Larson EH, Dobie SA. Medical students' attitudes toward abortion and other reproductive health services. Fam Med. 1999 Mar. 31(3):195-9. [Medline].
Sandstrom O, Brooks L, Schantz A, Grinsted J, Grinsted L, Jacobsen JD. Interruption of early pregnancy with mifepristone in combination with gemeprost. Acta Obstet Gynecol Scand. 1999 Oct. 78(9):806-9. [Medline].
Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol. 1996 May. 87(5 Pt 2):884-90. [Medline].
Schaff EA, Fielding SL. A comparison of the Abortion Rights Mobilization and Population Council trials. J Am Med Womens Assoc. 2000. 55(3 Suppl):137-40. [Medline].
Schaff EA, Fielding SL, Eisinger SH, Stadalius LS, Fuller L. Low-dose mifepristone followed by vaginal misoprostol at 48 hours for abortion up to 63 days. Contraception. 2000 Jan. 61(1):41-6. [Medline].
Schaff EA, Fielding SL, Westhoff C, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: A randomized trial. JAMA. 2000 Oct 18. 284(15):1948-53. [Medline].
Schüler L, Pastuszak A, Sanseverino TV, et al. Pregnancy outcome after exposure to misoprostol in Brazil: a prospective, controlled study. Reprod Toxicol. 1999 Mar-Apr. 13(2):147-51. [Medline].
Selam B, Lembet A, Stone J, Lapinski R, Berkowitz RL. Pregnancy complications and neonatal outcomes in multifetal pregnancies reduced to twins compared with nonreduced twin pregnancies. Am J Perinatol. 1999. 16(2):65-71. [Medline].
Selam B, Torok O, Lembet A, Stone J, Lapinski R, Berkowitz RL. Genetic amniocentesis after multifetal pregnancy reduction. Am J Obstet Gynecol. 1999 Jan. 180(1 Pt 1):226-30. [Medline].
Singh K, Ratnam SS. The influence of abortion legislation on maternal mortality. Int J Gynaecol Obstet. 1998 Dec. 63 Suppl 1:S123-9.
Sorosky JI, Scott-Conner CE. Breast disease complicating pregnancy. Obstet Gynecol Clin North Am. 1998 Jun. 25(2):353-63. [Medline].
Stephen JA, Timor-Tritsch IE, Lerner JP, Monteagudo A, Alonso CM. Amniocentesis after multifetal pregnancy reduction: is it safe?. Am J Obstet Gynecol. 2000 Apr. 182(4):962-5. [Medline].
Stotland NL. The myth of the abortion trauma syndrome. JAMA. 1992 Oct 21. 268(15):2078-9. [Medline].
Strauss LT, Herndon J, Chang J, Parker WY, Levy DA, Bowens SB. Abortion surveillance--United States, 2001. MMWR Surveill Summ. 2004 Nov 26. 53(9):1-32. [Medline].
Trussell J, Ellertson C. Estimating the efficacy of medical abortion. Contraception. 1999 Sep. 60(3):119-35. [Medline].
US Government Printing Office, Washington DC. Partial-Birth Abortion Ban Act of 2003.
Ventura SJ, Mosher WD, Curtin SC, Abma JC, Henshaw S. Trends in pregnancies and pregnancy rates by outcome: estimates for the United States, 1976-96. Vital Health Stat 21. 2000 Jan. (56):1-47. [Medline].
Vintzileos AM, Ananth CV, Smulian JC, Beazoglou T, Knuppel RA. Routine second-trimester ultrasonography in the United States: a cost-benefit analysis. Am J Obstet Gynecol. 2000 Mar. 182(3):655-60. [Medline].
Westfall JM, Sophocles A, Burggraf H, Ellis S. Manual vacuum aspiration for first-trimester abortion. Arch Fam Med. 1998 Nov-Dec. 7(6):559-62. [Medline].
Wiebe E, Guilbert E, Jacot F, Shannon C, Winikoff B. A fatal case of Clostridium sordellii septic shock syndrome associated with medical abortion. Obstet Gynecol. 2004 Nov. 104(5 Pt 2):1142-4. [Medline].
Wiebe ER. Comparing abortion induced with methotrexate and misoprostol to methotrexate alone. Contraception. 1999 Jan. 59(1):7-10. [Medline].
Wiebe ER. Tamoxifen compared to methotrexate when used with misoprostol for abortion. Contraception. 1999 Apr. 59(4):265-70. [Medline].
World Health Organization. Comparison of two doses of mifepristone in combination with misoprostol for early medical abortion: a randomised trial. World Health Organisation Task Force on Post-ovulatory Methods of Fertility Regulation. BJOG. 2000 Apr. 107(4):524-30. [Medline].
Wu S. Medical abortion in China. J Am Med Womens Assoc. 2000. 55(3 Suppl):197-9, 204. [Medline].
Borgatta L, Kapp N, Society of Family Planning. Clinical guidelines. Labor induction abortion in the second trimester. Contraception. 2011 Jul. 84 (1):4-18. [Medline].