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Specializing in Late Abortion for Fetal Disorders

ABORTION: Medical and Social Aspects
Warren M. Hern, M.D., M.P.H., Ph.D.

originally published in Encyclopedia of Marriage and the Family, Volume I
David Levinson, Editor in Chief. Simon & Schuster MacMillan, 1995.

Abortion is one of the most difficult, controversial, and painful subjects in modern American society. The principal controversy revolves around the questions of who makes the decision concerning abortion — the individual or the state; under what circumstances it may be done; and who is capable of making the decision. Medical questions such as techniques of abortion are less controversial but are sometimes part of the larger debate.

Abortion is not new in human society. A study by anthropologist George Devereux (1955) showed that more than three hundred contemporary nonindustrial societies practiced abortion. Women have performed abortions on themselves or experienced abortions at the hands of others for thousands of years (Potts et al. 1977), and abortions continue to occur today in nonindustrial societies under medically primitive conditions. However, modern technology and social change have made abortion an essential component of modern health care. However, abortion has become a political issue in American life and a flash point for disagreements about the role of women and individual autonomy in life decisions.

Definition of Abortion

The classic definition of abortion is "expulsion of the fetus before it is viable." This could include spontaneous abortion (miscarriage) or induced abortion, in which someone (a doctor, the woman herself, or a layperson) causes the abortion. Before modern methods of abortion, this sometimes meant the introduction of foreign objects such as catheters into the uterus to disrupt the placenta and embryo (or fetus) so that a miscarriage would result. In preindustrial societies, hitting the pregnant woman in the abdomen over the uterus and jumping on her abdomen while she lies on the ground are common techniques used to induce an abortion (Early & Peters 1990). Although these methods can be effective, they may also result in death of the woman if her uterus is ruptured or if some of the amniotic fluid surrounding the fetus enters her blood stream. From the Colonial period to the early twentieth century in America, primitive methods such as these were used along with the introduction of foreign objects into the uterus (wooden sticks, knitting needles, catheters, etc.) to cause abortion, frequently with tragic results (Lee 1969).

In modern American society, abortions are performed surgically by physicians or other trained personnel experienced in this technique, making the procedure much safer than when primitive methods were used. The goal of induced abortion still remains the same: Interrupt the pregnancy so that the woman will not continue to term and deliver a baby.

One problem with the classical definition of abortion is the changing definition of viability (the ability to live outside the womb). Premature birth is historically associated with high death and disability rates for babies born alive, but medical advances of the twentieth century have made it possible to save the lives of babies born after only thirty weeks of pregnancy when the usual pregnancy lasts forty weeks. Some infants born at twenty-six to twenty-seven weeks or even younger have survived through massive intervention and support. At the same time, abortions are now sometimes performed at up to twenty-five to twenty-six weeks of pregnancy. Therefore, the old definition of viability is not helpful in determining whether an abortion has been or should be performed (Grobstein 1988).

Reasons for Abortions

There are probably as many reasons for abortions as there are women who have them. Some pregnancies result from rape or incest, and women who are victims of these assaults often seek an abortion. Most women, however, decide to have an abortion because the pregnancy represents a problem in their lives. Some women feel emotionally unprepared to enter parenthood and raise a child; they are too young or do not have a reliable partner with whom to raise a child. Many young women in high school or college find themselves pregnant and must choose between continuing the education they need to survive economically or dropping out to have a baby. Young couples who are just starting their lives and want children might prefer to develop financial security first to provide better care for their future children. Sometimes people enter into a casual sexual relationship that leads to pregnancy with no prospect of marriage, but even if the sexual relationship is more than casual, abortion is sometimes sought because a woman decides that the social status of the male is inappropriate.

Some of the most difficult and painful choices are faced by women who are happily pregnant for the first time late in the reproductive years (thirty-five to forty-five) but discover in late pregnancy (twenty-six or more weeks) that the fetus is so defective it may not live or have a normal life. Even worse is a diagnosis of abnormalities that may or may not result in problems after birth. Some women and couples in this situation choose to have a late abortion (Hern et al. 1993, Kolata 1992).

In some cases, a woman must have an abortion to survive a pregnancy. An example is the diabetic woman who develops a condition in pregnancy called hyperemesis gravidarum (uncontrollable vomiting associated with pregnancy). She becomes malnourished and dehydrated in spite of intravenous therapy and other treatment, threatening heart failure, among other things. Only an abortion will cure this life-threatening condition.

In other cases, an abortion is sought because the sex of the fetus has been determined through amniocentesis or ultrasound examination and it is not the desired sex. This is more common in some cultures than in others. In the United States, it is exceedingly rare, and the request for abortion in this situation may be precipitated by the risk of a sex-linked hereditary disease.

Incidence of Abortion

If it were not for pregnancy, there would be no abortions. This rather obvious fact must be stated because it is not always noticed. To understand the numbers and rates of abortions, it is necessary to know the denominator: the total number of pregnancies. In the United States, about 6.2 million pregnancies occur each year, of which 1.6 million end in abortion and 4.6 million in live birth (Henshaw and Van Vort 1992; Koonin et al. 1991b). This gives an abortion ratio of 347.8 abortions per 1,000 live births. Since these 1.6 million abortions occur in approximately 67 million women in the reproductive ages (fifteen to forty-five), the abortion rate is 24 abortions per 1000 women fifteen to forty-five. In some areas where contraceptives are not widely available, such as the former Soviet Union and certain countries in Eastern Europe, the abortion rates and ratios are much higher. In Scandinavian nations, where contraceptives are more freely available and widespread sex education emphasizes prevention of pregnancy and sexually transmitted diseases, the abortion rates and ratios are much lower than in the United States (Hodgson, 1981).

The incidence of abortion (total number of cases per unit of time) may fluctuate, but the rates and ratios of abortion tend to remain steady. However, in the early 1970s, when abortion became legal in the United States with the Supreme Court decision in Roe v. Wade (1973), all three factors were affected. In addition, many illegal abortions performed before the 1970s were simply not reported, so the increase in reported incidence was to some extent an artifact of the changed legal climate. The number of abortions being performed did not change as much as the number of abortions being reported, and the number of deaths due to illegal abortion declined dramatically (Pakter 1977; Tietze 1975, 1977).

When abortion was illegal in the United States, even the many abortions performed properly by skilled physicians were not reported. Women without funds for a safe illegal abortion often committed desperate acts. Restrictions on legal abortion, including prohibition of public funding for the procedure, have produced some of the same results. Women have inserted harmful and even lethal substances such as lye into their vaginas in the mistaken belief that it will cause an abortion. Long knitting needles have been inserted into the uterus and moved around enough to cause an abortion. While this can cause an abortion, penetration of the uterine wall or other organs can occur and be fatal.

Risks of Abortion

Abortion has become not only the most common but also one of the safest operations performed in the United States. This was not always the case. In the nineteenth and early twentieth centuries, abortion was quite dangerous; many women died as a result.

Pregnancy itself is not a harmless condition, women can die during pregnancy. The maternal mortality rate (the proportion of women dying from pregnancy and childbirth) is found by dividing the number of women dying from all causes related to pregnancy, childbirth, and the puerperium (the six-week period following childbirth) by the total number of live births, then multiplying by a constant factor, such as 100,000. The maternal mortality rate in the United States in 1920 was 680 maternal deaths per 100,000 live births (Lerner & Anderson 1963). It had fallen to 38 deaths per 100,000 live births by 1960 and 8 deaths per 100,000 live births by 1994. Illegal abortion accounted for about 50 percent of all maternal deaths in 1920, and that was still true in 1960. By 1980, however, the percentage of deaths due to abortion had dropped to nearly zero (Cates, 1982). The difference in maternal mortality rates due to abortion reflected the increasing legalization of abortion from 1967 to 1973 that permitted abortions to be done safely by doctors in clinics and hospitals. The changed legal climate also permitted the prompt treatment of complications that occurred with abortions.

The complication rates and death rates associated with abortion itself can also be examined. In 1970, Christopher Tietze of the Population Council began studying the risks of death and complications due to abortion by collecting data from hospitals and clinics throughout the nation. The statistical analyses at that time showed that the death rate due to abortion was about 2 per 100,000 procedures, compared with the maternal mortality rate exclusive of abortion of 12 deaths per 100,000 live births. In other words, a woman having an abortion was six times less likely to die than a woman who chose to carry a pregnancy to term. Tietze also found, that early abortion was many times safer than abortion done after twelve weeks of pregnancy (Tietze and Lewit 1972) and that some abortion techniques were safer than others. The Centers for Disease Control and Prevention in Atlanta took over the national study of abortion statistics that had been developed by Tietze, and abortion became the most carefully studied surgical procedure in the United States. As doctors gained more experience with abortion and as techniques improved, death and complication rates due to abortion continued to decline. The rates declined because women were seeking abortions earlier during pregnancy, when the procedure was safer. Clinics where safe abortions could be obtained were opened in many cities across the country, improving access to this service.

By the early 1990s, the risk of death in early abortion was fewer than 1 death per 1 million procedures, and for later abortion, about 1 death per 100,000 procedures (Koonin et al. 1992). The overall risk of death in abortion was about 0.4 per 100,000 procedures, compared with a maternal mortality rate (exclusive of abortion) of about 9.1 deaths per 100,000 live births (Koonin et al. 1991a, 1991b).

When and How Abortions Are Performed

In the United States, more than 90 percent of all abortions are performed in the first trimester of pregnancy (up to twelve weeks from the last normal menstrual period). Most take place in outpatient clinics specially designed and equipped for this purpose. Nearly all abortions are performed by physicians, although two states (Montana and Vermont) permit physicians' assistants to do the procedure. A limited number of physicians in specialized clinics perform abortions during the second trimester of pregnancy, but only a few perform abortions after pregnancy has advanced to more than twenty-five weeks. Although hospitals permit abortions to be performed, the number is limited because the costs to perform an abortion in the hospital are greater and hospital operating room schedules do not allow for a large number of patients. In addition, staff members at hospitals are not chosen on the basis of their willingness to help perform abortions, while clinic staff members are hired for that purpose.

Most early abortions are performed with some use of vacuum aspiration equipment. A machine or specially designed syringe is used to create a vacuum, and the suction draws the contents of the uterus into an outside container. The physician then checks the inside of the uterus with a curette, a spoon-shaped device with a loop at the end and sharp edges to scrape the wall of the uterus (Hern 1990).

Before the uterus can be emptied, however, the cervix (opening of the uterus) must be dilated, or stretched, to introduce the instruments. There are two principal ways in which this can be done. Specially designed metal dilators, steel rods with tapered ends that allow the surgeon to force the cervix open a little at a time, are used for most abortions. This process is usually done under local anesthesia, but sometimes general anesthesia is used. The cervix can also be dilated by placing pieces of medically prepared seaweed stalk called laminaria in the cervix and leaving it for a few hours or overnight (Hern 1975, 1990). The laminaria draw water from the woman's tissues and swell up, gently expanding as the woman's cervix softens and opens from the loss of moisture. The laminaria are then removed and a vacuum canula or tube is placed into the uterus to remove the pregnancy by suction. Following this, the walls of the uterus are gently scraped with the curette.

After twelve weeks of pregnancy, performing an abortion becomes much more complicated and dangerous. The uterus, the embryo or fetus, and the blood vessels within the uterus are all much larger. The volume of amniotic fluid around the fetus has increased substantially, creating a potential hazard. If the amniotic fluid enters the woman's circulatory system, she could die instantly or bleed to death from a disruption of the blood-clotting system. This hazard is an important consideration.

Ultrasound equipment, which uses sound waves to show a picture of the fetus, is used to examine the woman before a late abortion is performed. Parts of the fetus such as the head and long bones are measured in order to determine the length of pregnancy. The ultrasound image also permits determination of fetal position, location of the placenta, and the presence of any abnormalities that could cause a complication during the procedure.

Between fourteen and twenty weeks of pregnancy, laminaria are placed in the cervix over a period of a day or two, sometimes changing the laminaria and replacing the first batch with a larger number to increase cervical dilation (Hern 1990). At the time of the abortion, the laminaria are removed, the amniotic sac (bag of waters) is ruptured with an instrument, and the amniotic fluid is allowed to drain out. This reduces the risk of an amniotic fluid embolism, escape of the amniotic fluid into the blood stream, and allows the uterus to contract to make the abortion safer. Using an ultrasound "real time" image, the surgeon then places special instruments such as grasping forceps into the uterus and removes the fetus and placenta (Hern, 1990). This has proven to be the safest way to perform late abortions, but it requires great care and skill.

Other methods of late abortion include use of prostaglandin (a naturally occurring hormone), either by suppository or by injection (Hern 1988). Other materials injected into the pregnant uterus to effect late abortion include hypertonic (concentrated) saline (salt) solution, hypertonic urea, and hyperosmolar (concentrated) glucose solution.

Injections are also used with late abortions, especially those performed at twenty-five weeks or more for reasons of fetal disorder. The lethal injection into the fetus is performed several days prior to the abortion along with other treatments that permit a safe abortion (Hern et al. 1993).

Physical and Psychological Effects of Abortion

Studies of the long-term risks of induced abortion, such as difficulties with future pregnancies, show that these risks are minimal. A properly done early abortion may even result in a lower risk of certain obstetrical problems with later pregnancies (Hern 1982; Hogue et al. 1982). An uncomplicated early abortion should have no effect on future health or childbearing. If the abortion permits postponement of the first-term pregnancy to after adolescence, the usual risks associated with a first-term pregnancy are actually reduced.

Psychological studies consistently show that women who are basically healthy can adjust to any outcome of pregnancy, whether it is term birth, induced abortion, or spontaneous abortion (miscarriage) (Adler et al. 1990). It is highly desirable, however, to have strong emotional support not only from friends and family, but also from a sympathetic physician and a lay abortion counselor who will be with the woman during her abortion experience. Most specialty abortion clinics now have abortion counselors who help women talk about their feelings before the abortion and to provide specific information about the procedure and its risks. This counseling is crucial not only in providing proper emotional and social support but also in helping the woman understand what she needs to know about the procedure and prevention of complications. Women who have this kind of support, as well as support from family and friends, generally have few psychological problems following abortion. On the other hand, women who have received hostile, punitive messages about the pregnancy and the decision to have an abortion are likely to experience high levels of stress during the abortion and in later years. These women may have a lingering sense of guilt for having decided to follow through with the abortion procedure.

Denial of abortion can have serious adverse consequences for the children who result from the pregnancies their mothers had wanted to terminate. A long-term study in Czechoslovakia of the offspring of women who were denied abortions has shown a range of adjustment and developmental difficulties in these children (David et al. 1988).

Social Responses to Abortion

The various social responses to abortion range from those of the individual and her immediate circle of family and friends to the organizational, community, and even national levels.

Individual. From an individual's point of view, a decision to have an abortion includes physical concerns (safety, pain, and long-term consequences), emotional aspects, ethical and religious concerns, and the effect on social relationships. These matters are sometimes restricted by laws and other societal regulation. No one has as much information about these issues as the woman who will make the decision, but even then, the decision is complicated and frequently not easy to make. Decisions are influenced by age, socioeconomic status, educational levels, community attitudes, and religious traditions (Ginsburg 1989; Luker 1984).

Family. An abortion affects not just one person, but many. A mother thinks about whether another child will make it more difficult to give the necessary love and support to the children she already has. The family may face stressful economic conditions that make it hard to make ends meet. A couple with two jobs may feel their lives will become impossible with the birth of a child. Whatever the decision, the couple's own parents, siblings, friends, and extended family may play a role by providing emotional support for or opposition to the decision.

The parents of pregnant teenagers who are considering an abortion often have a difficult time. They may wonder where they went wrong as parents, but even in families with a lot of love and good communication, this situation can arise. One recommended approach is to consider all the possibilities; abortion is not the best or only solution for everyone or every family. However, for an adolescent whose risk of serious obstetrical problems is higher than that of a postadolescent, an abortion may have the lowest possible medical risk.

Teenagers usually have difficulty discussing pregnancy, and especially sexual matters, with their parents, and parents generally have difficulty talking with their children about sex. Sometimes a teacher, cleric, or counselor can serve as an intermediary to facilitate this discussion.

Partner. Other than the woman, her sexual partner may be most directly affected by the abortion decision unless there is no emotional relationship or the woman has elected not to tell him. A woman's decision to have an abortion affects both lives profoundly, and research studies show it is better if the woman's partner is part of the decision and supportive (Shostak et al. 1984). Marriages are often made stronger by such a joint decision, regardless of whether the decision is to have an abortion or to continue the pregnancy. The woman cannot be forced to have an abortion, and she has the sole right under law to make the decision. However, unresolved conflict over such a decision can and often does lead to separation or divorce.

A decision to have an abortion is sometimes made in the context of a failing relationship when the woman perceives that her partner will not be there to help her take care of a baby if she continues the pregnancy to term. In this case, the woman not only experiences grief over the loss of the relationship but also loss with the end of the pregnancy, that symbolized a bond between her and her partner.

Community. Just as the individual decision-making process concerning abortion contains various components (physical, emotional, social, ethical), there are several levels or aspects to community response, including the general community response (Handwerker 1990). This response can range from public newspaper comment to visible protests and demonstrations in the local community. It can also be the focus of interest by local or national political groups and government attention.

In the United States, the majority of citizens think that abortion should be a matter between the woman and her physician. A small minority (about 12 percent) think that abortion should never be permitted under any circumstances. Polls show, however, that questions posing special cases (i.e. the woman's life is in danger, the pregnancy is the result of rape or incest) produce different responses (McKeegan 1992). Some who support choice would support certain restrictions (e.g., the need for parental consent for adolescents), and some who oppose abortion would grant certain exceptions (e.g., the woman's life is in danger).

There are many conflicting community responses, but among the most visible are the newspaper accounts, editorials, and published letters, some lacerating the writer's adversaries in harsh language. Part of the community response is the formation of organizations with strong belief systems that oppose or support abortion rights, and these groups work hard to mobilize people, sway public opinion, and influence public policy decisions. Some examples include Operation Rescue (opposed to choice) and the National Abortion Rights Action League (supportive of choice).

These community and national responses to abortion have sometimes taken the form of attempts to influence the political process and to codify community attitudes with the passage of local ordinances and federal legislation. Some communities, such as Boulder, Colorado, have displayed this polarization but have become increasingly supportive of choice (Hern 1991), as exemplified by the passage in 1986 of a city ordinance protecting women entering clinics from antiabortion protestors. This ordinance became the model for a similar Colorado statute. Nonetheless, antiabortion sentiment has prevailed in other communities.

Regardless of the particular community, however, the national antiabortion movement has become highly mobile, with groups such as Operation Rescue and the Army of God blocking access to clinics, disrupting normal activities around abortion clinics, and pressing antiabortion propaganda on women who seek services at clinics.

More than a thousand violent attacks on abortion clinics and doctors were reported to the National Abortion Federation from 1977 to 1991 (Grimes et al. 1991; Robey 1988), but many incidents went unreported. During this time, more than a hundred clinics and doctors' offices were destroyed by firebombs, arson, or explosives.

Personal attacks have also been made on doctors who perform abortions. These attacks range from public prayers of death (Booth and Briggs 1993, Johnson 1993) to assassinations and attempted assassinations (Bates 1993; Rohter 1993). As a result, many physicians perform abortions behind heavy security protection, even in communities that strongly support abortion rights (Gavin 1993; Hern 1993; Sanko 1993; Stolberg 1993)

National response to antiabortion violence has included passage of federal legislation providing stiff penalties for attacks on clinic workers and patients, signed into law by President Bill Clinton on May 26, 1994.

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Hern, W.M., "Abortion: Medical And Social Aspects." From Encyclopedia of Marriage and the Family, David Levinson, Editor. Vol. I, pp. 1-7. Copyright © 1995 by Macmillan Library Reference. Used by special permission granted to the author by Macmillan Library Reference, a Simon & Schuster Macmillan Company. Any further reproduction of this material is prohibited without the written consent of the publisher, whose address is 1633 Broadway, New York, New York 10019. Encyclopedia orders may be made toll-free to tel. 1-800-223-2336/fax 1-800-445-6991.

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